Charleston Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, Illinois.
- Location
- 716 Eighteenth Street, Charleston, Illinois 61920
- CMS Provider Number
- 145636
- Inspections on file
- 36
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Charleston Rehab And Nursing during CMS and state inspections, most recent first.
A resident with intact cognition, a history of paroxysmal atrial fibrillation, and a recent Covid-19 diagnosis experienced a rapid decline, including extreme weakness, shortness of breath, lethargy, and loss of ability to feed and care for himself. CNAs repeatedly reported these changes and the resident’s complaints of not feeling well to an LPN and an RN, but the LPN stated she was too busy with a med pass and did not promptly assess the resident. An RN documented a new-onset irregular heart rate of 111 bpm, but this abnormal finding was not reported to a provider, and the resident was not sent out for evaluation at that time. The facility’s change in condition policy, which required a full nursing assessment and provider notification for such changes, was not followed, and the resident was later hospitalized with Covid-19, acute renal failure, elevated troponin, hyperkalemia, dehydration, and atrial fibrillation with rapid ventricular response.
A resident with severe cognitive impairment and multiple comorbidities experienced three unwitnessed falls over several months. After the first fall, the only documented intervention was to ensure the call light was within reach, an approach already in place and later deemed inappropriate given the resident’s cognitive status, and no new toileting or environmental interventions were added. Following a second unwitnessed fall, staff again documented only education to use the call light. During a later fall, the resident was found on the floor between the bed and bathroom with a head bump, moaning and appearing in pain, and her wheelchair was across the room despite a care plan requiring assistive devices within reach. A CNA reported that an LPN did not perform a physical or neuro assessment and directed CNAs to get the resident back to bed, while the neuro assessment flow sheet showed the resident as stuporous and unable to follow directions but lacked all required subsequent neuro and vital sign entries and nurse signatures. Family and hospice were not notified until the next day, contrary to hospice protocol and facility policies that require immediate evaluation for injury, completion of neuro checks for possible head injury, and timely notification of the physician and responsible party.
The facility failed to thoroughly investigate two separate resident-to-resident verbal abuse incidents and did not remove an alleged perpetrator from a shared dining room after witnessed verbal abuse. In one case, a resident loudly cursed at another resident in the dining room, causing the victim to leave crying, while other residents were present; the aggressor admitted to yelling harsh words, and a staff member confirmed witnessing the event, yet the investigation did not include interviews with other residents and the aggressor remained in the dining room to finish the meal. In a second case, a resident told another that she hoped he would choke on his water and die, repeating the statement when questioned; although a CNA reported the incident to leadership, the investigation again lacked additional resident or staff interviews. The Administrator/Abuse Prevention Coordinator later acknowledged that both investigations were incomplete and that the aggressor in the dining room incident should not have remained there after the outburst.
A resident with a history of CVA, hemiplegia, aphasia, depression, pain, and unsteadiness, who used a manual w/c for mobility, experienced prolonged delays in transfer to a supportive living facility because the facility repeatedly failed to provide complete and accurate discharge documentation, including SS information, Medicare/Medicaid status, and resident funds records. Physician orders specified that the resident required a properly sized w/c with defined features for mobility, but there was no record that a new w/c was ordered, and the resident was discharged with her own older w/c, which was later observed to be in serious disrepair with cracked and broken side panels, missing plastic, and worn, flat cushioning. The resident and supportive living staff reported that she had requested a new w/c for months, that the facility gave inconsistent information about ordering it, and that the lack of proper documentation and failure to purchase the w/c delayed her admission and left her using the damaged device.
A resident with poor dentition and multiple decayed, broken teeth had a documented plan for monitoring mouth pain and obtaining dental consults as needed, including instructions to hold Eliquis prior to extractions. After a dental clinic determined that multiple extractions were needed, several scheduled appointments were repeatedly rescheduled: once because nursing staff did not hold required medications, once due to an incorrect belief that the resident’s insurance was canceled, and multiple times because the facility could not provide or arrange transportation following a change in van ownership and unresolved coordination with public transit. These combined failures in nursing preparation, insurance verification, and transportation scheduling led to a prolonged delay in completing the resident’s dental extractions.
A resident with multiple serious diagnoses, severe cognitive impairment, and on hospice services experienced a fall with a subsequent change in condition. The assigned LPN did not notify the resident’s family, physician, or hospice at the time of the incident, and the fall report documented no notifications. Family and the POA reported they were not informed until the next day, and hospice confirmed they were contacted the following morning. On assessment the next day, the resident was lethargic, unable to speak, and moaning. The DON later stated that immediate notification of family, provider, and hospice was standard practice, and the LPN acknowledged she had not made the required notifications.
A resident with a history of aggressive behaviors and psychiatric diagnoses verbally abused another resident with depression and psychosis in the dining room, repeatedly yelling profanities and telling the resident to shut up while the dining area was partially occupied. Multiple staff and residents witnessed the outburst, and the targeted resident became upset, cried, and left the dining room. Both residents were cognitively intact per recent MDS BIMS scores, and the aggressor’s care plan already identified a pattern of yelling and inappropriate interactions toward others, with interventions directing staff to intervene and monitor such behaviors. Despite a facility policy prohibiting verbal and mental abuse and requiring review of resident-to-resident altercations as potential abuse, the incident demonstrates that a resident was not kept free from emotional and verbal abuse by another resident.
A resident with hemiplegia, aphasia, and chronic pain, who relied on a manual wheelchair for mobility, repeatedly requested a replacement wheelchair due to severe disrepair of her long‑owned chair, including cracked and missing side panels and a worn, painful cushion. Despite physician orders specifying the need for a wheelchair and cushion at discharge and ongoing involvement from a Medicaid social worker seeking a new chair since 2022, the facility failed to provide required paperwork or arrange for a replacement. The resident was ultimately discharged with the same damaged wheelchair and reported prolonged discomfort and ongoing requests that were not acted upon, while the Administrator later confirmed the facility had not purchased a wheelchair and that the resident had requested one repeatedly over the prior year.
Two residents’ medical records were not accurately maintained. One resident experienced a verbal altercation with another resident in the dining room that led to crying and emotional distress, but the incident and subsequent emotional response were not documented or monitored in the medical record, despite the resident having depression and being cognitively intact. Another cognitively intact resident’s MDS inaccurately indicated no obvious cavities or broken teeth, while the care plan and direct observation showed poor dentition with multiple black, brown, broken, and chipped teeth and a reported plan for full dental extractions and dentures.
A resident with an indwelling catheter and multiple comorbidities developed a penile wound due to staff failing to secure the catheter as ordered, provide timely and complete wound care, and follow infection control protocols. The resident's prescribed zinc cream was not consistently available, wound care was incomplete, and proper documentation and monitoring were lacking, resulting in worsening of the wound and additional pain and treatment needs.
A resident who was cognitively intact reported that staff, including the DON and LPNs, laughed at her concerns about another resident and her own medical condition, which included an abscessed tooth and facial swelling. The resident felt sad and expressed a desire to leave the facility due to these interactions. The administrator acknowledged that staff should be more aware of their conversations when residents are present, in accordance with facility policy on resident rights.
Multiple residents experienced verbal and emotional abuse from both staff and other residents, including an LPN accusing a resident of faking seizures, a CNA mocking and intimidating a resident with cognitive impairment, and repeated verbal altercations between residents involving threats and derogatory language. These incidents were witnessed by staff and acknowledged as abusive under facility policy.
A cognitively intact resident reported that staff were not listening, laughed at her, and expressed a desire to leave AMA. These allegations of mental abuse involving staff were not reported to the State Agency as required, and the Administrator only became aware of the incidents through later record review, contrary to facility policy that mandates immediate reporting of abuse allegations.
A resident with dementia and severe cognitive impairment was able to leave the facility unnoticed through an unlocked and unalarmed exit door and courtyard gate, which were left unsecured to allow independent access for smoking and due to contractor activity. The resident was found outside by a CNA and returned to the facility. The facility's investigation did not identify the root cause or document the unsecured exits involved in the elopement.
A resident with severe cognitive impairment and a history of elopement risk exited the facility through an unlocked, unalarmed door and gate, and was found outside by a CNA. The incident and subsequent investigation were not documented in the resident's medical record, and the facility's investigation failed to identify or record the root cause or the status of the doors and gate involved.
Certified Nurse Assistants did not wear gowns while providing catheter and perineal care to a resident on Enhanced Barrier Precautions for a history of MDRO and an indwelling urinary catheter. Despite clear signage and facility policy requiring gown and glove use for high-contact care, staff provided care and emptied a urinary drainage bag without proper PPE, and the room lacked appropriate disposal bins for contaminated PPE.
A resident who recently returned from the hospital with acute respiratory failure and hypoxia became unresponsive and stopped breathing. During the emergency response, staff attempted to use the AED, but it was found to be nonfunctional due to lack of timely checks and maintenance. Staff proceeded with CPR and used an Ambu bag until EMS arrived, but the resident was later pronounced dead. The facility's policy required daily AED checks, which were not performed.
Several staff members, including the administrator, ADON, and a restorative CNA, consumed alcohol before entering the facility and subsequently performed clinical duties such as skills checks and medication management. Witnesses observed physical signs of intoxication, and the incident had the potential to impact all 54 residents, constituting a failure to maintain professional standards of conduct.
Two residents' privacy was compromised when a video of one resident was posted on social media by agency CNAs, and another resident received wound care with her door open, exposing her bare legs and medical condition to others. An LPN discovered and reported the social media post, and the second resident expressed embarrassment about her lack of privacy during treatment.
A resident with severe cognitive and physical impairments was subjected to mental abuse by two agency CNAs, who repeatedly locked the resident's wheelchair brakes while taunting him to move faster. The incident was recorded and posted on social media, showing the resident visibly distressed and unable to escape the situation. Staff who viewed the video described the actions as antagonizing and abusive, causing significant anxiety and confusion for the resident.
A significant medication error occurred when an agency nurse, on their second day at the facility, administered medications intended for one resident to another with a similar last name. The error happened in the dining room during breakfast, where the nurse gave the resident thin liquids instead of the required thickened liquids. The resident, who had chronic heart failure and impaired decision-making skills, experienced a drop in blood pressure after receiving the wrong medications. The facility's policies on medication administration were not followed.
The facility did not ensure the required Infection Preventionist attended the quarterly QAA meetings, and failed to hold these meetings quarterly. The absence of this key member was confirmed by the DON and Administrator, with meetings occurring before the Infection Control Preventionist's hire date. This oversight potentially affects all 60 residents, as the QAPI Program aims to monitor quality and performance.
The facility failed to maintain an operational Legionella water management plan, potentially affecting all 60 residents. The plan was last reviewed in 2018 and lacked necessary assessments and preventive measures. The Maintenance Director, in the role for four years, had not addressed the plan and was unaware of corporate guidance. The Regional Infection Preventionist confirmed the Maintenance Director's responsibility for the plan.
The facility's Infection Preventionist, temporarily filled by the Regional Infection Preventionist, failed to provide proof of specialized training in infection prevention and control, as required by the facility's Infection Control Manual. This deficiency affects all 60 residents, as the Infection Preventionist could not produce a training certificate and was unavailable to address the issue.
The facility failed to provide required abuse prevention education to staff, affecting all 60 residents. The Administrator confirmed the absence of documentation for staff education on abuse training, as the current management lacks access to previous records. The facility's policy mandates training during orientation, annually, and ongoing sessions, but this was not documented, resulting in the deficiency.
The facility failed to ensure call lights were within reach for four residents, despite care plans indicating high fall risk and the need for accessible call lights. Observations showed call lights on the floor or tied to objects, contrary to the facility's guidelines.
The facility failed to provide timely dining assistance to seven residents who required help with eating. During a dining observation, only one CNA was initially present to assist, leading to delays as residents waited for help. The facility's protocol, which emphasizes timely assistance and personal attention, was not followed, as confirmed by the Director of Nursing and resident reports of ongoing issues with late feeding and insufficient staff.
A resident with hypertension received spironolactone for 23 days despite an order to hold the medication due to symptoms of low blood pressure and dizziness. The facility resumed the medication without authorization, and the resident began refusing doses after experiencing adverse symptoms. The medical provider confirmed no order was given to resume the medication and later discontinued it.
Two residents with cognitive impairments were involved in a physical altercation, resulting in one resident sustaining a laceration. Despite the facility's policy to prevent abuse, the incident occurred, and staff were notified, including the police. The facility's report confirmed the altercation and documented the response to the injury.
The facility failed to conduct a thorough investigation into a resident-to-resident altercation, where one resident was injured. The investigation lacked comprehensive staff and resident interviews, contrary to the facility's abuse prevention policy, resulting in an incomplete understanding of the incident.
A facility failed to request a new Level 1 PASARR for a resident with an intellectual disability within 30 days of admission, as required. The resident's initial PASARR allowed a 30-day stay without further evaluation due to an exempted hospital discharge. The administrator confirmed that the PASARR was expired and a new request had not been made.
A facility failed to identify specific behaviors necessitating anti-psychotic medication for a resident and did not implement a care plan with non-pharmacological interventions. The resident was prescribed Risperidone for Major Depressive Disorder without documented targeted behaviors or psychic distress. Staff confirmed the lack of behavior tracking, and the resident rarely left their room.
The facility failed to administer physician-ordered treatments for two residents with skin conditions. One resident with eczema did not receive Tacrolimus cream and Calamine lotion as ordered, and the care plan was not updated. Another resident with a diabetic ulcer did not receive the newly ordered Medihoney and Calcium Alginate treatment, as the order was not entered into the medical record.
The facility failed to provide proper catheter care for three residents, leading to potential cross-contamination and increased risk of urinary tract infections. CNAs did not follow the facility's catheter care policy, resulting in improper cleaning techniques and unsecured catheter tubing and drainage bags. The care plans for these residents lacked necessary interventions and goals for catheter maintenance.
A facility failed to prevent the unnecessary use of Risperidone for a resident with Major Depressive Disorder and Anxiety Disorder, lacking an approved diagnosis for anti-psychotic use. No psychotropic medication assessment or behavior tracking was documented, and the resident did not exhibit behaviors necessitating the medication. The facility's policy requires such medications only for specific conditions, with assessments upon admission and quarterly, which were not conducted.
A resident with severe cognitive impairment had their food preferences disregarded when served a meal that included vegetables, despite documentation of their dislike for all vegetables. A CNA noted the untouched meal and confirmed the resident's preference, ordering an alternative meal. This incident highlights a failure to adhere to the facility's protocol of honoring food preferences before serving meals.
A resident was not offered the influenza vaccination in 2022 or 2023, despite the facility's policy to offer it to all residents. The resident had a history of receiving the vaccine from 2010 to 2021, but there is no documentation for the subsequent years. A registered nurse confirmed the lack of records for the resident's influenza vaccine.
A resident was not offered a COVID-19 vaccination booster despite expressing interest and not having received a vaccination since April 2021. A registered nurse confirmed that the resident was mistakenly not included in a vaccination clinic held in June 2024.
A resident with diabetes and cognitive impairment developed a diabetic foot ulcer that was not reported to a physician or treated promptly. The ulcer was discovered during a shower, but the facility failed to notify the physician or document the condition until weeks later, leading to a diagnosis of Osteomyelitis and subsequent hospitalization.
A resident with diabetes and chronic conditions developed a black sore on the right great toe, which was documented by a CNA and reported to a Charge Nurse. However, the physician and POA were not notified of this change in condition as required by facility policy. The Wound Weekly Evaluation later documented the wound, but there was a delay in notifying the family.
Failure to Respond to Significant Change in Condition for Resident With Covid and Atrial Fibrillation
Penalty
Summary
The deficiency involves the facility’s failure to recognize and respond to a significant change in condition for one resident with a known history of paroxysmal atrial fibrillation and a recent Covid-19 diagnosis. The resident’s care plan required staff to notify the physician of any abnormal readings. On a documented date, an RN obtained vital signs and recorded a new-onset irregular heart rate of 111 beats per minute. Despite this abnormal finding and the resident’s cardiac history, the irregular pulse was not reported to the physician or PA, and the resident was not sent out for evaluation at that time. The facility’s Change in Condition Procedure required a full nursing assessment, including full vital signs and evaluation of level of consciousness, respiratory status, abdomen, functional status, and pain, followed by notification of the medical provider, but this process was not followed. Multiple CNAs reported that during the period when the resident was ill with Covid, the resident experienced a rapid decline, including extreme weakness, shortness of breath, inability to feed or care for himself, lethargy, appearing dazed, and repeatedly stating he did not feel well. CNAs V6, V8, and V9 stated they repeatedly reported these concerns and the resident’s change in condition to an LPN and an RN, but the LPN repeatedly stated she was too busy with a medication pass to assess the resident and did not act on their concerns. The RN recalled CNAs reporting a significant change in the resident’s condition and that they had reported it to the LPN, who did not respond. The DON later assessed the resident and sent him to the hospital, where he was diagnosed with Covid-19, acute renal failure, elevated troponin, hyperkalemia, dehydration, and atrial fibrillation with rapid ventricular response. The PA stated that an irregular pulse of 111 in this resident should have been reported or resulted in an emergency room evaluation and that the resident’s clinical picture warranted further diagnostic testing.
Failure to Implement Targeted Fall Interventions and Complete Post-Fall Neurological Assessments
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate fall-prevention interventions, ensure needed mobility devices were within reach, and complete required post-fall assessments and notifications for a resident with severe cognitive impairment. The resident had multiple significant diagnoses, including senile degeneration of the brain, chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, chronic kidney disease stage IV, unsteadiness on feet, and lack of coordination. An MDS documented a Brief Interview of Mental Status score of 5/15, indicating severe cognitive impairment, and that the resident required supervision and contact assistance with toileting and used a wheelchair for mobility. On one date, the resident experienced an unwitnessed fall while attempting to get up to go to the bathroom and fell over a recliner chair footrest, striking her face on the floor. The fall investigation documented that the resident’s POA requested hospital transfer, and the resident returned with a small head laceration and no new orders. The facility’s fall log listed the intervention as ensuring the call light was within reach and functioning, an intervention that had already been in place and which the DON later confirmed was not appropriate for a resident with severe cognitive impairment. No new targeted interventions addressing toileting needs or the recliner footrest were documented after this fall. Later in the same month, the resident had another unwitnessed fall, was found on the floor, and could not state what happened. The only intervention documented was to educate the resident to use the call light and wait for assistance, which the DON again confirmed was not appropriate given the resident’s cognitive status. On a subsequent date, the resident had another unwitnessed fall while moving from one bed to another and was found on the floor between the bed and bathroom. The fall report documented a small bump to the head near the right eye, that vital signs were taken, the resident was helped back to bed, and again instructed to use the call light for help. The CNA who found the resident stated the wheelchair was across the room, out of the resident’s reach, despite a care plan intervention that assistive devices be kept within reach. The CNA reported the resident was mumbling, groaning, appeared in pain, had a large bump above the right eyebrow that swelled immediately, and was without oxygen. The CNA stated the LPN did not assess the resident, directed staff to get her up, and left the room, with another CNA later obtaining vital signs. The neurological assessment flow sheet initiated after this fall showed the resident as stuporous and unable to follow directions at the initial time, but all other required neurological and vital sign fields were left blank at that time and at all subsequent required intervals, with no nurse signature. The DON confirmed that neurological assessments were not completed, that there was no thorough investigation to determine root cause, and that appropriate notifications to family, physician, and hospice were not made. The MAR showed that ordered PRN lorazepam and morphine were not administered on the date of the fall, while family and hospice staff later reported the resident was lethargic, moaning, swollen and bruised, and appeared to have suffered a serious head injury and untreated pain. The facility’s own fall reduction and neurological assessment policies required evaluation for injury, neurological assessment for possible head injury, and timely notification of physician, responsible party, and hospice, which were not carried out in this case. Family members stated they were not notified of the fall when it occurred and only learned of it later, expressing that they would have come in immediately had they been informed. They also reported being told by a CNA that the nurse instructed CNAs to get the resident off the floor and back to bed without the nurse completing an assessment, and that the nurse said she would give morphine but was later observed at the desk on her phone and reading. Another LPN reported that when she came on duty the next day, there was no documentation that the prior LPN had completed neurological assessments or contacted the physician, hospice, or family, and that she herself then attempted to reach family and hospice, who came in right away. The hospice RN confirmed hospice was not notified until the following morning, despite hospice protocol requiring immediate notification of falls so hospice staff can assess the resident. The hospice RN described the resident as having been alert and conversational the day before the fall and as lethargic and unable to converse when seen the next morning, and stated that, based on her experience, the resident had likely sustained a concussion and brain bleed and needed earlier evaluation. The DON, after reviewing the fall investigations, care plans, assessments, neurological assessments, vital-sign documentation, interventions, and fall reports, confirmed that standard practice to thoroughly assess a resident post-fall was not followed. The DON verified that the interventions of reminding the resident to use the call light were not appropriate for a resident with severe cognitive impairment, that toileting should have been addressed after the first fall when the resident was attempting to go to the bathroom independently, that neurological assessments were not completed after the last fall, and that appropriate notifications to family, physician, and hospice were not made. The facility’s written policies on fall reduction and neurological assessment, which require evaluation for injury, use of neurological assessment guidelines for possible head injuries, and timely notification of physician, responsible party, and on-call nurse, were not adhered to in the resident’s case.
Failure to Thoroughly Investigate Resident-to-Resident Verbal Abuse and Remove Alleged Perpetrator from Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into two separate resident-to-resident verbal abuse allegations and to remove an alleged perpetrator from a shared dining room after witnessed verbal abuse. In the first incident, a state report dated 01/16/26 documents that an allegation of verbal abuse occurred between residents identified as R16 and R17 in the dining room. The facility’s investigation included staff witness statements but did not include interviews with other residents who were present in the dining room. Subsequent interviews revealed that another resident (R7) overheard R16 yelling “pretty bad words” at R17, causing R17 to leave crying, and another resident (R14), who dined at the same table as R16, recalled R16 “cussing up a blue streak” at R17 and described the behavior as uncalled for. R16 later admitted to yelling harsh curse words at R17 because he believed R17 was laughing at him, and R18, who was present, confirmed that R16 was agitated, yelled curse words, and that R17 left the dining room upset and crying. Despite this, R16 and R18 remained in the dining room to finish their meal, and a dietary assistant (V33) stated she witnessed the verbal abuse while other unidentified residents were present. In the second incident, a state report dated 12/12/25 documents an allegation of verbal abuse between residents R3 and R4 in a hallway near the nursing desk. A CNA (V50) reported that while charting at the nursing desk, she heard R3 cursing at R4 and telling him she hoped he would choke on his water and die; when R4 questioned what was said, R3 repeated the statement. V50 told R3 the behavior was not acceptable and removed her from the hall, then reported the incident to the Assistant DON (V51) and the Administrator/Abuse Prevention Coordinator (V1). R3 later did not recall the incident, and R4 stated he did not recall the exact words but knew R3 was not nice and cussed at him. The investigation documentation for this incident did not include additional resident or staff interviews beyond these statements. During review of the hard-copy investigations, the Administrator/Abuse Prevention Coordinator (V1) acknowledged that both investigations lacked witness statements from other residents, which are part of a thorough investigation, and also acknowledged she had misunderstood R16’s post-incident location and that R16 should not have remained in the dining room after shouting profanities at R17.
Failure to Provide Required Discharge Documentation and Appropriate Wheelchair for Resident Transfer
Penalty
Summary
The deficiency involves the facility’s repeated failure to provide complete and accurate documentation and personal records needed for a resident’s discharge and admission to a supportive living facility, as well as failure to obtain an appropriate wheelchair as ordered. The resident had a history of cerebral infarction with hemiplegia and hemiparesis affecting the right dominant side, foot drop, aphasia, expressive language disorder, major depressive disorder, pain, and unsteadiness on feet, and used a manual wheelchair for mobility. Physician orders documented that the resident was to be discharged to an assisted living facility and required a specific-sized wheelchair with defined features due to her cerebrovascular conditions, but there was no documentation in the medical record confirming that a new wheelchair had been ordered. On the day of discharge, the discharge summary noted that discharge education was performed, medications were sent with the resident, and that the resident took her own wheelchair and hemi-walker because they belonged to her. Subsequent observation at the supportive living facility showed the resident using a wheelchair in visible disrepair, including a cracked and broken plastic side panel near her hip, missing plastic on the armrest, and both armrests wrapped in thin elastic bandage tape. The resident reported that she had repeatedly requested a new wheelchair for months, including after becoming eligible for Medicare, and stated that the facility had told her at various times that a wheelchair was being ordered and later that it was not. She described the cushion as worn, tattered, and flat, and stated that the broken plastic poked and hurt her hip, requiring her to be extra careful. Interviews with the executive director and other staff at the supportive living facility revealed that they experienced numerous delays in obtaining the resident’s necessary documents from the skilled facility, including Social Security information, Medicare/Medicaid status, and accurate resident funds records. They reported that the skilled facility could not initially determine whether the resident was Medicaid or private pay, did not have an active Social Security card or award letter, and sent a commingled resident funds ledger with other residents’ information blacked out instead of a separate statement for this resident. These documentation issues, along with unresolved questions about the wheelchair order, caused months of delay in the resident’s admission to the supportive living facility despite her eligibility. The administrator of the skilled facility later confirmed that the delay in discharge was due to paperwork, identification records, and resident funds records not being submitted by the prior business office manager, and also confirmed that the facility did not purchase the resident’s wheelchair despite her repeated requests over the past year, resulting in her discharge with the broken wheelchair.
Failure to Provide Timely Dental Extractions Due to Missed Preparation and Transportation
Penalty
Summary
The deficiency involves the facility’s repeated failure to ensure transportation and appropriate nursing preparation for a resident’s needed dental extractions, resulting in prolonged delay of care. The resident had an MDS showing intact cognition and a care plan documenting poor dentition with obvious tooth decay, broken teeth, and goals to remain free from mouth pain, with instructions to observe for mouth pain and obtain dental consults as needed. A county health department dental consultation documented that the resident was to have multiple tooth extractions and that Eliquis was to be held for 24 hours before the procedure. Despite this, a scheduled dental appointment was rescheduled because nursing staff did not hold the resident’s medications as ordered, and the Regional Director later confirmed that this appointment should have been kept and that nurses should have been aware of the medication hold requirement. Further delays occurred due to administrative and transportation issues. Another dental appointment was rescheduled because the resident’s insurance was incorrectly believed to be canceled, although the Regional Business Office Manager later stated this was a mistake and that the resident had active Medicaid coverage at the time. Additional appointments were rescheduled when the facility could not provide transportation after a change in facility ownership and while the new operator was researching insurance and title for the facility van, and because the van driver/scheduler was unable to secure local public transportation. The van driver/scheduler reported that all appointments had been pushed out by weeks and that the resident’s dental work had been on hold for a couple of months. As a result, the resident, who had multiple black and brown broken teeth with only three upper and three lower chipped teeth remaining, experienced a delay of approximately ten months from the initial visit when extractions were determined to be needed.
Failure to Notify Family, Physician, and Hospice After Resident Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s family, physician, and hospice following a fall and change in condition. The resident had multiple serious diagnoses, including carcinoma of the left bronchus, senile degeneration of the brain, chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, stage IV chronic kidney disease, muscle disorder, unsteadiness on feet, and lack of coordination, and was admitted to hospice with a prognosis of six months or less. The resident’s MDS showed a Brief Interview for Mental Status score of 5/15, indicating severe cognitive impairment. A fall incident report documented that the resident fell at 7:30 p.m. on 12/06/25, with the assigned LPN identified, and specifically noted “No notifications found.” The facility’s Fall Reduction Policy required evaluation for injury and notification of the physician, responsible party, and on-call nurse after a change in condition, and the hospice contract required facility staff to contact hospice’s Administrator on Call for services related to the terminal illness. Interviews and record review confirmed that no notifications were made the night of the fall. Family members and the resident’s Power of Attorney reported they were not notified of the 12/06/25 fall until the following day, 12/07/25. An LPN coming on duty the next morning stated she learned of the fall during shift report and found no documentation that the physician, hospice, or family had been notified; she then attempted to reach family and hospice. At that time, the resident was described as lethargic, unable to speak, and moaning. The hospice RN confirmed hospice was not notified until the morning after the fall and stated that, based on her experience, the resident had a concussion and likely a brain bleed and was comatose post-fall with changes in swallowing and breathing and no emotional response. The DON stated that the resident’s family, provider, and hospice should have been called immediately, and the LPN who was on duty at the time of the fall acknowledged it had been a hectic night and she had not notified the family, physician, or hospice.
Failure to Protect a Resident From Verbal Abuse by Another Resident in the Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from resident-to-resident verbal and emotional abuse in the dining room. One resident (R16), who had documented behavioral issues including aggression and inappropriate yelling or arguing with others, verbally targeted another resident (R17) during a meal. R16 had diagnoses of undifferentiated schizophrenia and bipolar disorder and was receiving risperidone; his MDS BIMS score was 15/15, indicating no cognitive impairment. R17 had diagnoses of unspecified depression and unspecified psychosis and was receiving sertraline and aripiprazole; his BIMS score was 14/15, also indicating no cognitive impairment. On the date of the incident, multiple witness statements described a verbal exchange in the dining room. Dietary staff reported that R17 was in the dining room joking and laughing with staff when R16 suddenly yelled, “Shut the (F-expletive) up,” and repeatedly used the F-word while looking at R17. One dietary assistant stated she initially assumed the yelling was directed at R17 and told R16 that the dining room was everyone’s home. Another dietary assistant and the cook both confirmed that R16’s profanity was directed at R17, that the dining room was about half full at the time, and that R17 became upset and left the dining room crying shortly afterward. Other residents (R7 and R14) also reported overhearing R16 yelling “pretty bad words” and “cussing up a blue streak” at R17 in the dining room, which they felt was uncalled for. R17 later stated that he cried and returned to his room when R16 would not stop cussing at him, explaining that he had depression and that being yelled at with profanities was overwhelming. During a subsequent interview, R17 became tearful while recounting the event. In a later interview, R16 admitted that he “put (R17) in his place,” acknowledged yelling harsh words because he thought R17 was laughing at him, and confirmed that R17 later came to him crying and asking if they were still friends. The facility’s own policy on Resident Right to Freedom from Abuse, Neglect and Exploitation defines verbal and mentally abusive behaviors, requires associates not to use verbal or mental abuse, and directs the facility to review resident-to-resident altercations as potential abuse situations. Despite this, the incident as described shows that R17 was subjected to witnessed resident-to-resident verbal and emotional abuse in the dining room. The facility’s care plan for R16 documented a known pattern of aggressive behaviors toward other residents, including yelling or arguing inappropriately and sometimes following others while continuing to be rude or inappropriate. Interventions in the care plan required staff to intervene when R16 exhibited behaviors toward other residents, ensure everyone’s safety, and monitor all inappropriate behaviors, including type, time, provocation, staff present, and resolution. Nonetheless, on the day of the incident, R16’s verbally aggressive behavior toward R17 occurred in a public dining setting, was witnessed by staff and residents, and resulted in R17 becoming emotionally distressed and leaving the dining room in tears. This sequence of events demonstrates that the facility did not ensure that R17 was free from resident-to-resident emotional and verbal abuse as required by its own policy and resident rights. Additionally, the Administrator/Abuse Prevention designee acknowledged during interview that the investigation of the allegation that R16 verbally abused R17 in the dining room had not yet been fully processed or scanned, even though the incident had occurred earlier. The facility’s policy states that when abuse is identified, the facility will take appropriate steps to remediate noncompliance and protect residents from additional abuse, including reviewing resident-to-resident altercations as potential abuse. The documented witness accounts, resident interviews, and R16’s own admission collectively establish that a resident-to-resident verbal abuse incident occurred and that the facility failed to ensure R17’s right to be free from such abuse.
Failure to Obtain Replacement Wheelchair Resulting in Prolonged Use of Damaged Equipment
Penalty
Summary
The deficiency involves the facility’s failure to obtain and arrange for a replacement wheelchair for a dependent resident, resulting in prolonged use of a wheelchair in disrepair. The resident had multiple neurologic and functional diagnoses, including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, right foot drop, aphasia, expressive language disorder, major depressive disorder, recurrent pain, and unsteadiness on feet. The resident’s MDS documented use of a manual wheelchair for mobility, and the MAR showed ongoing use of extended-release Tylenol for pain management up to the date of discharge. Physician orders documented that the resident required a wheelchair and cushion for discharge, specifying wheelchair dimensions, cushion thickness, and bilateral swing-away footrests. Surveyor observation at the supportive living facility after discharge found the resident using a wheelchair with the left arm in visible disrepair: the plastic side panel holding the armrest was cracked into several pieces, with a two-inch section of broken plastic bent inward and wrapped in thin elastic bandage tape, abutting the resident’s left hip. A five-inch section of plastic was missing from the same armrest, and the right armrest was wrapped in disposable elastic bandage material. The resident reported that the cushion was worn, tattered, flat, and caused discomfort to her buttocks, and that the broken plastic side panel poked and hurt her hip, requiring her to be extra careful to avoid being jabbed. The discharge summary documented that the resident left with her several-years-old wheelchair and hemi-walker, which belonged to her, and did not indicate that a new wheelchair had been provided. The resident stated she had asked and begged for a new wheelchair for months while at the facility, including after becoming eligible for Medicare, and that facility staff, including the Administrator, repeatedly told her they would check into it but did not follow through. She reported that the facility at one point said they were purchasing a wheelchair and later said they were not, and that she remained uncomfortable in her old wheelchair, which she had used for years since her stroke. The Meridian Medicaid social worker reported attempting to obtain a new wheelchair for the resident since 9/12/22, repeatedly requesting necessary paperwork from the facility and being told the paperwork was lost under both old and new ownership. The social worker stated that the resident’s wheelchair was in bad shape and cutting into her side, and that Medicaid would have provided a new wheelchair if the facility had supplied the required documentation. The Administrator confirmed that the facility did not purchase the resident’s wheelchair and that the resident had repeatedly requested a new one over the past year.
Failure to Maintain Complete and Accurate Medical Records for Emotional Distress and Dental Status
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with a BIMS score indicating no cognitive impairment, an incident of resident-to-resident verbal abuse in the dining room was reported to the state but not documented in the resident’s medical record. The incident involved another resident yelling profanities, including the F-word and telling the resident to “shut up,” causing the resident to cry and return to their room. The resident, who has depression, reported feeling overwhelmed and was observed tearing up when recounting the event. There was no documentation in the medical record of the altercation, the resident’s crying episodes, or any monitoring of the resident’s emotional response such as anxiety, fear, or increased depression. For another resident, the facility’s MDS documented no obvious or likely cavities or broken natural teeth, despite other records and observations indicating significant dental problems. The resident’s care plan documented poor dentition with obvious tooth decay, and on interview the resident reported dental issues and a plan to have all teeth extracted and replaced with dentures. Direct observation showed multiple black and brown broken teeth worn down to the gum level, with only six remaining chipped, darkly discolored teeth. The administrator confirmed that the MDS coding for this resident’s dental status was incorrect and inconsistent with the resident’s other medical records and current oral health condition.
Failure to Provide Timely and Complete Catheter and Wound Care, Leading to Penile Injury
Penalty
Summary
A resident with multiple complex medical conditions, including chronic kidney disease, urinary retention, and an indwelling urethral catheter, was admitted to the facility without any penile wounds. The resident required significant assistance with personal care and was dependent on staff for toileting. The care plan instructed staff to anchor the catheter tubing high on the resident's thigh to prevent pulling and reduce the risk of injury, and to monitor and report any redness or skin issues. Despite these instructions, the catheter was repeatedly found unsecured, and the resident developed redness, excoriation, and eventually an open, bleeding wound on the penis. Staff failed to provide timely and complete catheter and wound care as ordered. The resident's physician ordered zinc cream to be applied twice daily to the penile wound, but documentation shows that the cream was not available on multiple occasions, and the treatment was not consistently administered. Additionally, staff did not fully retract the resident's foreskin during perineal and wound care, resulting in incomplete cleansing and assessment of the wound. There was also a lack of proper wound documentation, including measurements and drainage assessment, and the facility was unable to provide records of ongoing wound monitoring. Infection control practices were not followed during wound care. A CNA and an RN both failed to change gloves or perform hand hygiene between cleansing the wound and applying the prescribed zinc cream, and the RN applied the cream with contaminated gloves. The catheter remained unsecured during care, and staff acknowledged not following proper procedures. The DON confirmed that the penile wound was caused by constant pulling of the catheter and that the facility should not have run out of zinc oxide. The resident's wound worsened during the stay, and the facility could not provide adequate documentation of wound assessment or monitoring.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
A cognitively intact resident (R8) reported that staff failed to treat her with dignity and respect. According to the Minimum Data Set and nurse progress notes, the resident was observed crying and stated that staff were not listening to her, laughed at her, and made her feel sad. The resident also expressed a desire to leave the facility Against Medical Advice (AMA) due to these interactions. The resident recounted an incident where she was concerned about another resident who was screaming, and when she went into the hallway, the Director of Nursing (DON) was reportedly yelling and laughing at her. Additionally, the resident described having an abscessed tooth with significant facial swelling and stated that when she informed staff, including the DON and two LPNs, they yelled and laughed at her concerns. The facility's administrator acknowledged that staff should always treat residents with dignity and respect and recognized the need for staff to be more aware of their conversations when residents are present. The facility's policy, approved in December 2024, affirms each resident's right to a dignified existence, self-determination, and communication without interference or reprisal. The events described indicate that the facility failed to uphold these rights for the resident involved.
Failure to Protect Residents from Verbal and Emotional Abuse
Penalty
Summary
The facility failed to protect residents from verbal and emotional abuse by both staff and other residents, as evidenced by multiple incidents involving seven residents. One resident with epilepsy and a seizure disorder was repeatedly accused by an LPN of faking seizures, both privately and in front of others, causing the resident to feel upset, embarrassed, and mistrusted. This was corroborated by a CNA who witnessed the LPN making disparaging remarks about the resident's condition in the resident's presence. Another incident involved two residents with cognitive impairments and behavioral concerns who engaged in a verbal altercation, with one threatening physical harm and the other responding with derogatory language. Staff confirmed that the altercation required intervention and separation. Additional cases included a resident with panic disorder and cognitive impairment who was prevented from leaving the dining room by a CNA, who also mocked and intimidated the resident, causing visible distress. This behavior was witnessed and described as mentally abusive by other staff members. Further deficiencies were noted when a CNA provided discourteous and physically rough care to a resident with dementia and mobility issues, including shoving the resident and making callous remarks about the risk of falling. There were also repeated instances of one resident with severe cognitive impairment verbally abusing another resident, using profane and derogatory language in common areas. Staff and the administrator acknowledged these behaviors and confirmed that such actions are considered abuse under facility policy.
Failure to Timely Report Allegations of Mental Abuse
Penalty
Summary
The facility failed to report allegations of mental abuse involving a cognitively intact resident on two separate occasions. According to the resident's medical record, the resident was observed crying and reported that staff were not listening to her, were laughing at her, and that she wanted to leave against medical advice. Despite these documented concerns, the allegations of mental abuse involving staff members were not reported to the State Agency as required. The Administrator stated that she was not made aware of the resident's allegations on the dates they occurred and only discovered the issue through her own review of the resident's records at a later date. Facility policy requires that all allegations of abuse be reported immediately to the Administrator, who is responsible for overseeing investigations. In this case, the required reporting process was not followed, and the allegations were not communicated to the appropriate authorities in a timely manner.
Failure to Supervise Exit Doors and Investigate Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment by leaving an exit door and a courtyard gate both unlocked and unalarmed, which allowed a resident with severe cognitive impairment and a diagnosis of dementia to elope from the building unnoticed. The resident, who was independently mobile and had a recent mental status change, was found walking outside along the building perimeter by a Certified Nursing Assistant (CNA) who observed the resident through a window while providing care to another individual. The resident stated they were trying to go home and appeared disoriented, but was able to return to the facility with staff assistance. At the time of the incident, the courtyard gate was left open and unlocked due to a mowing contractor's access, and the hallway exit door was routinely kept unlocked and unalarmed to allow residents who smoke to access the courtyard without staff supervision. The facility's elopement investigation did not identify or document the root cause of the incident, nor did it note that the exit door and courtyard gate were unsupervised, unlocked, and unalarmed at the time of the elopement. The facility's policy requires adequate supervision and a root cause analysis following an elopement, but the investigation failed to address these requirements. The resident's care plan indicated minimal staff assistance was needed for ambulation, but assessments documented severe cognitive impairment and elopement risk factors.
Failure to Document Resident Elopement and Investigation
Penalty
Summary
The facility failed to document an elopement incident and subsequent investigation in the medical record of a resident with dementia, weakness, muscle wasting, and severe cognitive impairment. The resident, who was independently mobile and assessed as at risk for elopement, was found outside the facility by a CNA after exiting through an unlocked and unalarmed door leading to a courtyard, and then through an unlocked gate to the sidewalk. The incident was observed by staff, and the resident was returned to the facility without any door alarms sounding. The unlocked gate was attributed to a mowing contractor's access, and the exit door was routinely left unlocked and unalarmed to allow residents to access a smoking area. Despite the occurrence of the elopement, there was no documentation of the incident in the resident's nursing progress notes or electronic medical record, except for a note in a risk section not typically accessible to medical or nursing staff. The facility's elopement investigation did not identify or document the root cause of the incident, nor did it note the status of the doors and gate at the time. The Director of Nursing was unsure if the elopement was documented in the resident's medical record, confirming the lack of proper documentation.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Certified Nurse Assistants (CNAs) failed to wear the required gowns while providing direct care, including indwelling urinary catheter care and perineal care, to a resident on Enhanced Barrier Precautions (EBP) due to a history of Multi Drug Resistant Organism (MDRO) and the presence of an indwelling urinary catheter. During the observed care, the CNAs did not don gowns as required by facility policy, despite signage indicating EBP precautions outside the resident's room. Additionally, one CNA emptied the resident's urinary drainage bag without wearing a gown. The room lacked appropriate disposal bins for contaminated Personal Protective Equipment (PPE), and no disposed PPE was found in the room's garbage cans. Both CNAs acknowledged after the incident that gowns should have been worn during these care activities. The Assistant Director of Nursing/Infection Preventionist confirmed that staff are expected to use appropriate PPE, including gowns and gloves, when providing high-contact care to residents on EBP, particularly those with a history of MDRO and indwelling devices. Facility policy specifies that gown and glove use is required during high-contact activities such as hygiene care and care involving indwelling medical devices.
Failure to Maintain AED Results in Nonfunctional Equipment During Cardiac Emergency
Penalty
Summary
The facility failed to ensure timely checks and maintenance of its medical equipment, specifically the Automated External Defibrillator (AED). According to interviews and record reviews, the AED was not checked daily as required, and the last documented check occurred at the end of June. On the day of the incident, when a resident returned from the hospital with a diagnosis of acute respiratory failure with hypoxia, the resident experienced an episode of not breathing and became unresponsive. Staff followed protocol by moving the resident to his room, placing him on the bed with a cardiac board, and retrieving the code cart and equipment. During the emergency response, the RN attempted to use the AED on the resident, but the device would not function. The RN was unsure if the battery was dead or if there was another issue. As a result, staff proceeded with chest compressions and used an Ambu bag while waiting for EMS to arrive. EMS took over upon arrival, but the resident was pronounced dead after 20 minutes of resuscitation efforts. The facility's policy required daily checks and maintenance of the AED, but this was not followed, leading to the equipment being nonfunctional during a critical event.
Staff Performed Clinical Duties After Consuming Alcohol
Penalty
Summary
Facility staff, including the previous administrator, assistant director of nursing (ADON), and a restorative certified nursing assistant (CNA), admitted to consuming alcoholic beverages a few hours before entering the facility. On the evening in question, these staff members attended a local bar/restaurant, where more than one drink was consumed by some of them. Later that night, they entered the facility and performed work-related duties, including conducting skills checks with staff and assisting with medication management. Multiple witness statements and employee corrective action forms confirm that these staff members were present in the facility after drinking alcohol. Observations included glassy eyes, rosy faces, and hyperactive behavior from the restorative CNA, as well as similar physical signs in the ADON. The staff members interacted with other employees, observed resident care, and participated in clinical activities while under the influence of alcohol. No direct harm to residents was reported, but the conduct was noted as a violation of professional standards and facility policy. The incident had the potential to affect all 54 residents residing in the facility, as documented in the facility's resident matrix. The facility's assessment outlines the necessary resources and staff roles required to provide competent care, which were compromised by the actions of the involved staff members. The deficiency centers on the failure to maintain a professional standard of conduct by allowing staff to work under the influence of alcohol while performing duties within the facility.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to protect the privacy and confidentiality of two residents' personal and medical information. In the first instance, a video of a resident with severe cognitive impairment, Alzheimer's disease, and Parkinson's disease was posted on social media by two agency CNAs. The video was discovered by an LPN, who saw it on a social media story while at work. The video depicted the resident in the facility and was shared without authorization, violating the facility's HIPAA protocol and resident privacy policies. The facility's own protocol explicitly prohibits the unauthorized disclosure of resident information on internet sites and emphasizes the importance of maintaining privacy. In the second instance, a resident with no cognitive impairment, diagnosed with bilateral lower leg cellulitis and lymphedema, was observed receiving wound care in her room with the door wide open. The resident's bare legs and feet, which were affected by severe dryness, scaling, and pitting edema, were in clear view of multiple unidentified residents, staff, and visitors passing by. The wound care process resulted in visible skin debris falling to the floor, further exposing the resident's condition. The resident expressed embarrassment about her condition being visible to others and stated a preference for privacy during treatments. Both incidents demonstrate a failure to ensure privacy during care and to protect confidential resident information, as required by facility policy and residents' rights. The actions and inactions of staff in both cases directly led to the exposure of residents' private information and personal dignity.
Mental Abuse of Resident by Agency CNAs via Social Media Video
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, cognitive communication deficit, Parkinson's disease, and generalized anxiety disorder, who was severely cognitively impaired and dependent on staff for mobility, was subjected to mental abuse by two agency CNAs. The incident involved the CNAs repeatedly locking the resident's wheelchair brakes while taunting him to move faster, despite his inability to do so. The CNAs took turns locking and unlocking the wheelchair, causing visible distress, anxiety, and confusion in the resident, who was unable to understand or respond appropriately due to his cognitive and physical limitations. The abuse was recorded on video and posted to social media by one of the CNAs, with the other CNA re-posting it. The video showed the resident in a corner, facing a blank wall, being taunted and prevented from moving. Observers of the video, including an LPN and another CNA, described the resident as appearing very upset, anxious, and in distress throughout the duration of the video, which lasted less than a minute. The actions of the CNAs were described as antagonizing and intended to cause mental harm, with the resident unable to escape or defend himself due to his condition and the physical restraint imposed by the staff. The facility's abuse prevention policy explicitly prohibits all forms of abuse, including mental abuse facilitated by technology such as unauthorized video recordings and social media posts. The policy defines mental abuse to include humiliation, harassment, and the use of recordings in a manner that demeans or humiliates residents. The actions of the CNAs, as documented in the video and described by staff, were in direct violation of this policy, resulting in the resident being subjected to mental anguish and humiliation.
Medication Error Due to Resident Misidentification
Penalty
Summary
The facility failed to correctly identify a resident before administering medications, resulting in a significant medication error. An agency nurse, on their second day at the facility, mistakenly administered medications intended for one resident to another resident with a similar last name. This error occurred in the dining room during breakfast, where the nurse gave the resident thin liquids instead of the required thickened liquids, despite a CNA's intervention. The resident who received the wrong medications had a primary diagnosis of chronic heart failure and was severely impaired in decision-making skills. The medications administered included a range of drugs such as antiarrhythmics, anticoagulants, antihypertensives, and others, which were not prescribed for the resident. This led to a drop in the resident's blood pressure, as confirmed by the facility's medical staff and the medical director. The facility's policies require adherence to the five rights of medication administration, which were not followed in this instance. The facility had a binder with policies and procedures for new and agency staff, but the nurse did not adhere to these guidelines. The incident was documented, and the facility acknowledged the significant medication error.
Failure to Include Infection Preventionist in QAA Meetings
Penalty
Summary
The facility failed to ensure that the required personnel attended the quarterly Quality Assessment and Assurance (QAA) committee meetings and did not hold these meetings quarterly as mandated. Specifically, the facility's QA Meeting Members list lacked the required Infection Preventionist, and the attendance sheets for the meetings did not include the signature of an Infection Control Preventionist. The absence of this key member was confirmed by the Director of Nursing and the Administrator, who acknowledged that the meetings occurred before the Infection Control Preventionist was hired on August 1, 2024. Additionally, there was no documentation of a first quarterly QA Meeting for 2024, and the second quarter meeting held in June 2024 also lacked the presence of an Infection Control Preventionist. This oversight has the potential to affect all 60 residents residing in the facility, as the QAPI Program is designed to monitor quality and performance, find opportunities for improvement, and meet regulatory requirements. The facility's failure to include an Infection Control Preventionist in these critical meetings indicates a lapse in adhering to the QAPI Program's comprehensive approach to maintaining and improving safety and quality.
Failure to Maintain Legionella Water Management Plan
Penalty
Summary
The facility failed to maintain an operational Legionella water management plan, which could potentially affect all 60 residents. The Legionella Management Procedure was last reviewed in 2018 and lacked an assessment to identify areas where Legionella and other pathogens could grow and spread, as well as measures to prevent and monitor the growth of waterborne pathogens. The Maintenance Director, who has been in the position for about four years, admitted to not having done anything with the Legionella water management plan since starting and stated that corporate had never discussed it with him. He also acknowledged not having assessed the building for potential growth areas of Legionella or other pathogens and did not have a routine to flush unused water lines. The Regional Infection Preventionist confirmed that the Maintenance Director was responsible for implementing and following the facility's Legionella water management plan.
Infection Preventionist Lacks Required Training Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist completed specialized training in infection prevention and control, as required by their Infection Control Manual dated 2019. This deficiency potentially affects all 60 residents in the facility. During an interview, the Director of Nursing stated that the Regional Infection Preventionist was acting as the facility's Infection Preventionist until a facility nurse could be trained for the role. However, the Regional Infection Preventionist was unable to provide a copy of her training certificate. Despite attempts to locate the certificate, it was not found, and the Infection Preventionist was not present at the facility as expected to resolve the issue.
Lack of Staff Training on Abuse Prevention
Penalty
Summary
The facility failed to provide the required abuse prevention education to its staff, which has the potential to affect all 60 residents. During a survey, the Administrator and Abuse Prevention Coordinator confirmed that there was no facility-wide documentation of staff education on abuse training available. The current management company does not have access to the previous owner's education documents. The facility's policy on abuse prevention and prohibition, revised in January 2024, outlines that staff should be trained on the Abuse Prohibition Program during orientation, annually, and ongoing educational sessions, as per state regulations. However, this training was not documented, leading to the deficiency.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, as observed during a survey. The Certified Nursing Assistant's Guidebook from 2021 mandates that call lights should be within reach before leaving a resident's room. However, during observations, it was noted that the call lights for four residents were not accessible. For instance, one resident's call light was found on the floor at the foot of the bed, while another's was tied to a stuffed animal on a bedside table, out of reach. These observations were made despite care plans indicating that these residents were at high risk for falls and required their call lights to be within reach as an intervention. The care plans for the residents involved documented specific interventions to ensure call lights were accessible, highlighting the importance of this measure due to their high fall risk. Despite this, the facility did not adhere to these interventions, as evidenced by the call lights being placed on the floor or tied to objects, making them inaccessible. The Assistant Director of Nursing confirmed that all residents' call lights should be within reach at all times, indicating a lapse in following established protocols and care plans designed to prevent falls and ensure resident safety.
Failure to Provide Timely Dining Assistance
Penalty
Summary
The facility failed to provide timely dining assistance to seven residents who required physical staff assistance with eating. During a dining observation, it was noted that these residents were seated at a designated table for those needing assistance, with their meals served and uncovered, but only one CNA was present to assist them initially. This resulted in a delay, as the CNA began feeding one resident while the others waited. A second CNA joined 21 minutes later to assist another resident, leaving five residents still waiting for help. The Director of Nursing later confirmed the lack of adequate staff to assist the residents and acknowledged that residents should not have to wait 40 minutes for assistance. The facility's protocol for communal dining emphasizes the importance of timely assistance and personal attention to residents during meals. However, the observation and resident council meeting minutes indicated that the facility did not adhere to these guidelines, as residents reported ongoing issues with late feeding and insufficient staff. The facility's protocol also specifies that no more than two residents should be assisted by one CNA at a time, a guideline that was not followed during the observed dining period.
Failure to Hold Blood Pressure Medication as Ordered
Penalty
Summary
The facility failed to adhere to a medical provider's order to hold the administration of a resident's blood pressure medication, spironolactone, resulting in the resident receiving the medication for an additional 23 days without authorization. The resident, who was diagnosed with hypertension, was initially ordered spironolactone along with other blood pressure medications. On August 6, 2024, the resident's medical provider documented symptoms of nosebleed, dizziness, and low blood pressure, leading to an order to hold the spironolactone indefinitely. Despite this order, the facility's Medication Administration Records show that the medication was only held from August 7 to August 9, 2024, and then resumed from August 10 to September 1, 2024. The resident began refusing further doses on September 2, 2024, after experiencing symptoms of low blood pressure and dizziness. The medical provider confirmed that there was no order to resume the medication, and subsequently discontinued the spironolactone on September 5, 2024.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents, R44 and R58. On the date of the incident, R58, who has schizophrenia and dementia with psychosis, grabbed R44's arm, leading to a physical altercation. R44, who has moderate cognitive impairment, responded by swinging an empty coffee cup at R58, although no contact was made. R44 sustained a small laceration on his right forearm during the incident. The incident was documented in R58's Resident to Resident Physical Aggression Initiated form, which noted R58's history of wandering and cognitive impairment. R58's Minimum Data Set (MDS) indicated moderate cognitive impairment and behaviors of wandering and delusions. R44's MDS also indicated moderate cognitive impairment and behaviors of verbal aggression. The altercation was confirmed by the facility's Administrator/Abuse Prevention Coordinator, who substantiated the allegation of physical abuse. The facility's policy on abuse prevention and prohibition emphasizes the right of residents to be free from abuse by anyone, including other residents. Despite this policy, the incident occurred, and staff were notified, including the local police, the Administrator, and the Director of Nursing. The facility's final report confirmed the physical altercation and documented the staff's response in assessing and treating R44's injury. However, the report highlights a failure to prevent the incident and protect the residents involved.
Incomplete Investigation of Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into a physical abuse incident involving two residents, R44 and R58. The incident occurred when R58, unprovoked, approached R44, who was in a wheelchair near the nurse's station, and grabbed R44's right arm, causing a laceration. The altercation escalated when R44 attempted to defend himself by swinging a cup at R58. Despite the presence of staff, the investigation was incomplete, lacking interviews with all staff and residents involved or present during the incident. The facility's final report included only two witness statements from CNAs, without any resident interviews or additional staff input. The facility's policy on abuse prevention and investigation mandates a comprehensive investigation, including interviews with all staff on duty during the incident and any residents who might have witnessed or been affected by the event. However, this protocol was not followed, as confirmed by the facility's Administrator and Regional Administrator. The investigation did not include interviews with all staff members present during the shift, nor did it involve interviews with the residents involved or other potential witnesses. This oversight resulted in an incomplete understanding of the incident and whether the alleged abuse was substantiated.
Failure to Request New PASARR for Resident with IDD
Penalty
Summary
The facility failed to request a new Level 1 PASARR (Preadmission Screening and Resident Review) within 30 days of admission for a resident identified as R32, who was reviewed for PASARR compliance. R32's initial Level 1 PASARR indicated evidence of a serious mental or intellectual disability and noted that further PASARR was not required due to an exempted hospital discharge, allowing a stay of up to 30 days in a Medicaid-certified nursing facility without further evaluation. However, the facility did not submit a new Level 1 screen to Maximus by the 30th day after R32's admission, as required. This oversight was confirmed during an interview with the facility's administrator, who acknowledged that the current PASARR for R32 was expired and that a new request had not been made.
Failure to Identify Behaviors and Implement Care Plan for Anti-Psychotic Use
Penalty
Summary
The facility failed to identify specific behaviors in a resident that necessitated the use of anti-psychotic medication and did not develop or implement a care plan with non-pharmacological interventions before administering the medication. This deficiency affected one resident, who was prescribed Risperidone for Major Depressive Disorder. The resident's care plan lacked documentation of targeted behaviors or expressions of psychic distress, and no non-pharmacological interventions were noted. A quarterly assessment indicated the resident did not exhibit indicators of psychosis or behaviors. Interviews with facility staff confirmed the absence of behavior tracking for the resident, who seldom left their room.
Failure to Administer Physician-Ordered Treatments for Skin Conditions
Penalty
Summary
The facility failed to apply treatments as ordered by the physician and care plan interventions for two residents reviewed for skin conditions. One resident, who has a history of eczema, was observed with multiple scabbed areas and red flaky patches on the skin, with blood under the fingernails, indicating self-inflicted scratches due to excessive itching. The resident's physician had ordered Tacrolimus cream and Calamine lotion for treatment, but these were not documented in the Medication and Treatment Administration Records after a certain date, and the care plan was not updated with these interventions. The wound nurse confirmed that the Tacrolimus cream was effective and should have been a current order, and the assistant director of nursing acknowledged that the absence of documentation likely meant the cream was not used. Another resident had a diabetic ulcer on the left foot, with the dressing observed to be saturated with yellow and red drainage, and the presence of slough and eschar in the wound beds. The wound nurse stated that the treatment order had changed to Medihoney and Calcium Alginate due to the wound's condition, but this new order was not entered into the medical record. The registered nurse applied betadine instead of the newly ordered treatment, indicating a failure to administer the correct treatment as per the updated physician's order.
Improper Catheter Care and Maintenance
Penalty
Summary
The facility failed to provide proper catheter care for three residents, leading to potential cross-contamination and increased risk of urinary tract infections. For one resident, a CNA used a no-rinse wipe improperly by not changing the area of the wipe when cleaning different parts of the resident's body, including the penis and buttocks. Additionally, the CNA did not anchor the catheter tubing at the meatus, causing unnecessary pulling on the catheter. The facility's policy requires changing the position of the cloth with each cleansing stroke and securing the catheter, which was not followed in this instance. Another resident was observed with their urinary catheter drainage bag laying flat on the floor, uncovered, and the catheter tubing was not secured to the leg. The resident's care plan did not include interventions or goals for catheter care and maintenance. Similarly, a third resident's catheter drainage bag was also found laying on the floor. The facility's catheter care policy, which aims to prevent catheter-associated urinary tract infections, mandates that catheter tubing and drainage bags be kept off the floor and secured, which was not adhered to in these cases.
Failure to Prevent Unnecessary Use of Anti-Psychotic Medication
Penalty
Summary
The facility failed to prevent the unnecessary use of the anti-psychotic medication Risperidone for a resident identified as R20. The resident's Order Summary Report listed diagnoses of Major Depressive Disorder and Anxiety Disorder, but did not include any approved diagnosis for the use of anti-psychotic medication. Despite the prescription of Risperidone for Major Depressive Disorder, there was no documentation of a psychotropic medication assessment or any specific targeted behaviors or indicators of persistent psychiatric distress that would necessitate the use of such medication. Interviews with the Assistant Director of Nursing and Registered Nurses revealed that there was no behavior tracking conducted for R20, and the resident did not exhibit indicators of persistent psychiatric distress or behaviors endangering themselves or others. The facility's policy on psychotropic medication use stipulates that such medications should only be administered when necessary for specific conditions, and a Psychoactive Medication Review assessment should be completed upon admission and quarterly. However, these procedures were not followed for R20, leading to the inappropriate continuation of anti-psychotic medication without a valid diagnosis or documented need.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as R34, who was reviewed for food preferences among a sample of 39 residents. R34 has a severe cognitive impairment, as indicated by a Brief Interview of Mental Status score of three out of 15. The resident's diet order specifies a regular diet with mechanical soft texture and honey/moderately thick consistency liquids. R34's lunch meal ticket, which was undated, documented a dislike for all vegetables. However, during an observation on September 5, 2024, a Certified Nursing Assistant (CNA) identified as V7 was feeding several residents and noted that R34's plate, which included mechanical soft meat, mashed potatoes, and whole cooked cauliflower, was untouched. V7 confirmed that R34 did not like the served meal and had ordered a grilled cheese instead. The CNA also confirmed that R34's diet card indicated a dislike for vegetables, yet the plate included cauliflower, contrary to the facility's protocol to honor residents' food preferences before serving meals.
Failure to Offer Influenza Vaccination
Penalty
Summary
The facility failed to offer influenza vaccinations to a resident, identified as R6, as part of their immunization protocol. According to the facility's Infection Prevention and Control Manual dated September 2022, it is the policy to offer influenza vaccinations to all residents. However, a review of R6's immunization report revealed that while the resident routinely received the influenza vaccine from 2010 to 2021, there is no documentation of the vaccine being offered or administered in 2022 or 2023. Furthermore, R6's medical record lacks any indication that the influenza vaccination was offered during these years. During an interview on September 6, 2024, a registered nurse (V8) confirmed the absence of records for R6's influenza vaccine for the years in question.
Failure to Offer COVID-19 Booster to Resident
Penalty
Summary
The facility failed to offer a COVID-19 vaccination booster to a resident, identified as R36, who was part of a sample list of 39 residents reviewed for immunizations. On September 3, 2024, R36 reported not being offered any vaccinations since being admitted to the facility and expressed a desire to receive the COVID-19 booster. The resident's immunization record indicated that the last COVID-19 vaccination was administered on April 1, 2021. On September 6, 2024, a registered nurse, identified as V8, confirmed that a COVID-19 vaccination clinic was held in June 2024 by an outside organization, but R36 was not included on the list for the clinic, resulting in the resident not being offered the vaccine.
Failure to Notify Physician and Obtain Treatment for Diabetic Ulcer
Penalty
Summary
The facility failed to notify the physician of a new diabetic foot ulcer, obtain a treatment order, and complete wound assessments for a resident with a history of Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Chronic Diastolic Heart Failure. The resident, who was moderately cognitively impaired and required assistance for all activities of daily living, was found to have a black sore on the right great toe during a shower on 5/21/24. This information was reported to the Charge Nurse, and a bandage was applied, but there was no documentation that the physician was notified of the change in the resident's skin condition. The lack of documentation and notification continued until 6/11/24, when the Wound Nurse completed a Weekly Skin Check and noted the new area on the resident's right great toe. The resident was subsequently diagnosed with Osteomyelitis and started on antibiotics. The resident's condition worsened, leading to hospitalization for IV antibiotics and a scheduled toe amputation. The facility's policy required weekly skin checks and immediate notification of the provider and resident representative upon identifying new skin conditions, which was not followed in this case.
Failure to Notify Physician and POA of Resident's Diabetic Ulcer
Penalty
Summary
The facility failed to notify the physician and the Power of Attorney (POA) of a resident's change in condition, specifically regarding diabetic ulcers on the resident's right great toe. The resident, who has Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure, was found to have a black sore on the right great toe during a shower on 5/21/24. This was documented by a CNA and reported to the Charge Nurse, who applied ointment and a bandage. However, there were no progress notes indicating that the physician or POA were informed of this change in the resident's skin condition on that date. Further investigation revealed that the Director of Nurses and the Wound Nurse were unaware of the shower sheet or progress note about the resident's toe. The Wound Weekly Evaluation form documented the wound on 6/10/24, with clinician notification on the same day and family notification on 6/12/24, indicating a delay in communication. The facility's policy requires monthly skin checks and immediate notification of medical practitioners and resident representatives for any newly identified issues, which was not adhered to in this case.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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