Clark-lindsey Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Urbana, Illinois.
- Location
- 101 West Windsor Road, Urbana, Illinois 61801
- CMS Provider Number
- 145381
- Inspections on file
- 24
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Clark-lindsey Village during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments was left without timely incontinence care and repositioning by staff, resulting in significant pain and distress. During a transfer, two CNAs improperly positioned the resident, ignored requests for assistance, and forced the resident to have a bowel movement in a garbage can. Staff then left the resident soiled and in pain, while family and private caregivers were compelled to provide essential care due to ongoing staff neglect. Facility leadership failed to act on repeated complaints or follow abuse prevention policies.
A resident who was cognitively impaired and fully dependent on staff for care received medications from an unlicensed private caregiver and the resident's POA, rather than from licensed nurses. Nursing staff routinely provided medications to these untrained individuals for administration, citing lack of time to wait for the resident to take her medications. Facility policy required licensed nurses to administer medications and remain with the resident, but this was not followed, and medications and supplies were left in the resident's room for unlicensed administration.
Nursing staff failed to accurately document medication administration for a resident who was fully dependent on staff, instead providing medications to the resident's POA and private caregivers and signing the MAR as if they had administered the medications themselves. This practice was inconsistent with facility policy and resulted in inaccurate medical records.
A resident who was cognitively intact and required assistance with daily activities was not allowed to eat breakfast in the dining room as she preferred, due to staffing shortages. Her care plan did not address her right to make choices, and staff confirmed that multiple residents were unable to go to the dining room for meals because of insufficient staff. The interim DON acknowledged the issue, noting that resident care requests should be honored.
A resident who was cognitively impaired and fully dependent on staff experienced pain and distress during a transfer, leading to a grievance raised by the resident's POA regarding care quality and staff behavior. Despite multiple communications, the facility did not document, follow up, or resolve the grievance, and the designated Grievance Officer was not informed, contrary to facility policy.
A resident who was cognitively impaired and fully dependent on staff was left in pain and distress during a transfer, forced to have a bowel movement in a garbage can, and not provided with necessary incontinence care or repositioning. The resident's POA and private caregivers reported ongoing neglect and were required to provide most care themselves. Despite being informed of the incident and ongoing concerns, facility leadership did not report the allegation of neglect to the State Surveying Agency as required by policy.
A resident who was cognitively impaired and fully dependent on staff was left in pain and without proper incontinence care after an incident involving improper use of a mechanical lift. The resident's POA and private caregivers reported ongoing neglect and lack of staff response, but the facility did not investigate or report the allegation as required by policy.
A resident admitted after a craniectomy did not receive physician-ordered daily skin checks, antiseptic shampoo, or required helmet use, and Enhanced Barrier Precautions were not implemented. Staff failed to monitor or document the surgical site, did not use appropriate PPE, and used standard soap instead of the ordered antiseptic. These failures led to a surgical site infection requiring antibiotics, hospitalization, and surgical debridement.
A resident with significant medical needs reported to their spouse that their head was bumped during a transfer for a shower, and the spouse informed an LPN. Although the LPN and DON checked for injury and found none, no immediate investigation or follow-up was conducted, and the incident was not documented or addressed according to the facility's grievance policy until a month later.
A resident with significant neurological and mobility impairments reported her head was bumped during a shower transfer, causing pain at a previous incision site. Although the incident was reported to an LPN by the resident's husband, no investigation or care plan update was initiated until more than a month later. Staff involved were not questioned about the event until much later, and the facility did not follow its policy for prompt incident reporting and investigation.
A resident with poor core strength fell from a reclining wheelchair that was not fully reclined, resulting in a head injury and hematoma. The facility also failed to maintain safe equipment, as sharp bolts under the wheelchair armrests caused skin tears. Additionally, the resident was improperly transferred using a sit-to-stand lift instead of a full mechanical lift, as required.
The facility failed to ensure dietary staff followed the hair restraint policy, risking food contamination. A cook was observed with a stocking cap that inadequately covered their hair, and the Dining Services Supervisor was seen without a beard net. These actions could affect all 20 residents.
A resident sustained skin tears from sharp bolts on a wheelchair, which was not promptly identified or repaired by the facility. The DON and Maintenance Director were initially unaware of the wheelchair's location, and it was later found in the physical therapy office, potentially still in use by other residents.
The facility failed to promptly notify a resident's Power of Attorney about skin tears and did not inform a physician about another resident's significant weight gain. The first resident's injury was reported to the Power of Attorney hours after it occurred, and the second resident's weight gain was documented but not communicated to the physician.
The facility did not follow its abuse prevention policy when a resident's Power of Attorney reported concerns of potential abuse to the DON. The Administrator failed to notify the state agency or investigate the allegation. Furthermore, the DON had not received the required abuse training, as indicated by the facility's records.
A facility failed to report an abuse allegation to the State Agency. A resident's Power of Attorney reported concerns to the DON about the resident saying 'Don't hurt me' during care. The Administrator received this allegation but did not notify the state agency, and the resident's medical record lacked documentation of such notification.
A facility failed to investigate an abuse allegation involving a resident who expressed distress during care. The resident's Power of Attorney reported the concern to the DON, who then informed the Administrator. Despite this, the Administrator did not conduct an investigation, and the resident's medical record showed no documentation of any follow-up.
A facility failed to update a resident's care plan to reflect a change from a mechanically altered diet to a pureed diet with nectar thickened liquids, as ordered by a physician. The oversight was discovered when the resident's water pitcher contained regular water, contrary to the prescribed diet. The Care Plan Coordinator acknowledged the failure to update the care plan.
A facility failed to develop a care plan for a resident on Hydrocodone-Acetaminophen, neglecting to address constipation, a known side effect. Despite receiving the medication twice daily, the resident had no bowel movement for six days, and no interventions were initiated, contrary to the facility's bowel protocol. Staff confirmed the lack of bowel movements and interventions.
A facility failed to follow proper hand hygiene and glove-changing protocols during incontinence care for a resident with a history of UTIs. Two CNAs assisted the resident to the toilet, but one CNA did not change gloves or sanitize hands after cleansing the perineal area and before applying a new incontinence brief, acknowledging the oversight.
A facility failed to document behaviors and implement non-pharmacological interventions before increasing an antidepressant dosage for a resident with Dementia, Anxiety, and Insomnia. The facility's policy requires such documentation and attempts at Gradual Dose Reductions (GDR) unless contraindicated. However, there was no documentation of behaviors or non-pharmacological interventions prior to increasing Remeron, nor was there an attempt or declination of a GDR for Sertraline within the last year.
The facility failed to properly store medications, including schedule II controlled substances, as per policy. An LPN found an unlocked refrigerator containing Lorazepam and expired medications in the storage area. Additionally, a resident had an Albuterol inhaler stored improperly on a bookcase. The DON confirmed these storage issues, which violated the facility's medication storage policy.
A resident with dysphagia was not provided with the prescribed pureed diet and thickened liquids, as the facility gave regular water with a straw and non-pureed food. The DON and an Advanced Nurse Practitioner confirmed the facility's failure to adhere to the dietary orders, leading to a deficiency in care.
Two CNAs failed to follow proper hand hygiene protocols, leading to potential cross-contamination. One CNA did not change gloves or sanitize hands after providing incontinence care to a resident, while another handled soiled items and assisted residents without performing hand hygiene. These actions violated the facility's infection control policy.
Failure to Protect Resident from Abuse and Neglect by Staff
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, protein-calorie malnutrition, and significant physical impairments, was not provided with timely and appropriate care by facility staff. The resident was completely dependent on staff for all activities of daily living, including repositioning, incontinence care, feeding, and medication administration. According to the care plan, staff were instructed to anticipate and meet the resident's needs, including frequent position changes and incontinence care at least every two hours. However, interviews and review of camera footage revealed that staff often failed to enter the resident's room for extended periods, sometimes up to six or eight hours, leaving the resident without necessary care. On a specific occasion, two CNAs transferred the resident using a mechanical lift and toilet sling. During the transfer, the resident was improperly positioned, resulting in significant pain and distress, as evidenced by the resident's crying, screaming, and yelling. The resident continued to have a bowel movement during the transfer, and instead of repositioning the resident or returning her to the toilet as requested by her power of attorney, the staff placed a garbage can under her, forcing her to have a bowel movement in it. The staff then left the resident on her bed without completing incontinence care or ensuring she was safely positioned, leaving her soiled and in pain. The resident's family and private caregivers reported that they were frequently required to provide all aspects of care, including repositioning, feeding, and medication administration, due to staff neglect. Facility leadership was made aware of these concerns, but failed to take appropriate action. The interim DON acknowledged receiving multiple complaints from the resident's power of attorney and confirmed that staff should be providing care every two hours. Despite requests to prevent the involved CNAs from caring for the resident, they continued to do so. The administrator in training admitted that the facility did not follow its abuse policy and did not properly report or investigate the incident. The facility's own policy states that residents must be free from abuse and neglect, and that staff must intervene to prevent such occurrences, but these standards were not upheld in this case.
Unlicensed Individuals Administered Medications Without Nurse Supervision
Penalty
Summary
Licensed nurses at the facility failed to administer medications as required, instead allowing an unlicensed private caregiver and the resident's Power of Attorney (POA) to administer medications on multiple occasions. The resident in question was documented as moderately cognitively impaired and completely dependent on staff for all activities of daily living, including eating, oral hygiene, toileting, showering, dressing, bed mobility, and transfers. The resident had multiple physician orders for daily and scheduled medications, including antibiotics, supplements, and medications for chronic conditions. Despite these needs, observations and interviews revealed that the private caregiver, who was not a licensed nurse and had no formal training in medication administration, was routinely given the resident's medications by nursing staff to administer without supervision. The private caregiver reported that nurses told her and other caregivers they did not have time to wait for the resident to take her medications, as she was a slow swallower. The caregiver described daily practices of mixing and administering medications, including thickening liquids and crushing pills, without knowledge of proper dosages, side effects, or potential interactions. The nurse confirmed that she prepared the medications and provided them to the POA or private caregivers for administration, stating that this was a common practice among staff and approved by facility administration. The Interim Director of Nursing (DON) also acknowledged giving approval for the POA and private caregivers to administer medications without a nurse present, despite their lack of licensure or training. Facility policy required that licensed nurses administer medications, remain with the resident until the medication is swallowed, and not leave medications in the resident's room without orders. The policy also specified that medications must be administered by legally authorized and trained persons in accordance with applicable laws and standards of practice. However, observations showed that medications, thickener, and pill crushers were left in the resident's room, and the private caregivers continued to administer medications daily, contrary to facility policy and regulatory requirements.
Inaccurate Medication Administration Records Due to Improper Delegation
Penalty
Summary
Facility staff failed to maintain accurate medical records and safeguard resident-identifiable information for one resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including medication administration. The resident's physician orders included multiple daily and twice-daily medications for various conditions, such as recurrent urinary tract infections, vaginal candidiasis, and chronic health issues. Despite these orders, nursing staff, including an RN and an LPN, reported that they routinely provided the resident's medications to the resident's Power of Attorney and private caregivers, rather than administering the medications themselves. Both staff members admitted to signing the Medication Administration Record (MAR) as if they had administered the medications, even though they could not confirm the medications were actually given to the resident. The facility's policy required that nurses document medication administration in the MAR immediately after personally administering the medication to each resident. The policy also specified that medications must be administered by legally authorized and trained persons in accordance with applicable laws and accepted standards of practice. The interim Director of Nursing confirmed that staff are expected to document only the work they perform and to ensure that medications are administered before signing the MAR. The actions of the nursing staff, as described in interviews and record reviews, were inconsistent with both facility policy and professional standards, resulting in inaccurate medical records for the resident.
Failure to Honor Resident's Right to Make Choices Due to Staffing Issues
Penalty
Summary
A cognitively intact resident who requires assistance with eating, oral hygiene, dressing, bed mobility, and transfers was not provided with the opportunity to exercise her right to make choices about her daily routine. The resident's care plan did not include any focus area, goal, or interventions related to her right to make her own choices. On the morning in question, the resident expressed a preference to get up earlier and eat breakfast in the dining room to socialize with other residents, but was instead served breakfast in bed due to reported staffing shortages. The resident stated that while she understood the staff were working hard, it had become the norm for her to eat breakfast in bed because of low staffing, which was not her preference. Staff interviews confirmed that there were not enough staff available that morning to assist all residents who wished to go to the dining room for breakfast. A CNA acknowledged that several residents who would normally eat in the dining room could not do so due to lack of staff, and that residents should be able to go to the dining room if they choose. The interim DON stated that the facility met regulatory staffing requirements but recognized that resident care requests should be honored and was aware of the staffing concerns on the resident's hall. The facility's failure to honor the resident's right to make choices about her daily routine, specifically regarding meal location and timing, was directly linked to staffing issues and lack of care plan interventions.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to document, follow up, and resolve a grievance for one resident who was moderately cognitively impaired and required maximum assistance for all activities of daily living. The resident's Power of Attorney (POA) reported an incident where the resident, while being transferred using a mechanical lift, was not positioned correctly, resulting in the resident screaming in pain and being forced to have a bowel movement in a garbage can. The POA communicated these concerns multiple times, including via email, and specifically requested that the involved CNAs not provide further care to the resident. Despite these requests, the same CNAs continued to care for the resident, and the POA was told by the Interim DON that no further action could be taken and that the CNAs were not the resident's primary caregivers. The facility did not maintain a grievance log or reports for the past three months, and the Interim DON did not report the POA's concerns to the designated Grievance Officer, believing the concerns did not warrant being classified as a grievance. The Administrator in Training was informed of the situation but was told by the Interim DON that it was being handled and did not need to be elevated to a grievance report. The Grievance Officer later confirmed that the concerns should have been reported as a grievance, as per facility policy, which allows grievances to be raised by residents, representatives, staff, or visitors and does not require a formal written complaint.
Failure to Report Alleged Neglect and Inadequate Resident Care
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including personal hygiene, eating, toileting, and mobility. The resident's Power of Attorney (POA) reported that the resident often waited 30-60 minutes for staff to respond to call lights and that personal cameras in the resident's room showed staff not entering for multiple hours. On the date of the incident, two CNAs used a mechanical lift with a toilet sling to transfer the resident, during which the resident was improperly positioned, experienced pain, and was left exposed and distressed. The POA witnessed the resident being forced to have a bowel movement in a garbage can while screaming in pain, and the CNAs refused to reposition the resident or provide further care, leaving the resident soiled and uncomfortably positioned in bed. The POA and private caregivers reported that they were required to provide most of the resident's care, including repositioning, feeding, administering medications, and hygiene, due to staff neglect. The POA communicated these concerns, including the specific incident, to the Interim DON via email and requested that the involved CNAs not provide further care to the resident. Despite these communications, the CNAs continued to care for the resident, and the DON responded that they were not the resident's primary CNAs, so it was acceptable. The POA was told by the DON that no one else could address the ongoing care concerns. The Administrator in Training (AIT) acknowledged being made aware of the family's concerns but stated that the Interim DON was handling the situation and did not escalate the issue or report it as a grievance. The facility did not report the allegation of neglect to the State Surveying Agency as required by their abuse prevention policy, which mandates immediate reporting of abuse or neglect allegations. Both the AIT and Interim DON confirmed that the incident was not reported, and the facility did not follow its own abuse policy.
Failure to Investigate and Report Allegation of Resident Neglect
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including personal hygiene, eating, toileting, and mobility. The resident's Power of Attorney (POA) reported that the resident was left waiting for extended periods for staff assistance, and that on one occasion, the resident was improperly positioned in a mechanical lift, causing pain and distress. During this incident, the resident was forced to have a bowel movement in a garbage can while in pain and was left without proper incontinence care or safe repositioning in bed. The POA and private caregivers reported that they frequently had to provide all care, including medication administration, due to staff neglect and lack of timely response to call lights. Despite the POA's immediate report of the incident to the Interim Director of Nursing (DON) via email, there was no documented investigation into the allegation of neglect. The POA and private caregivers were not interviewed for witness statements, and the staff members involved continued to provide care to the resident after the incident. The Interim DON acknowledged receiving the complaint and stated that the staff involved reported the incident a week later, but no formal investigation was initiated, and the allegation was not reported to the State Agency as required by facility policy. The Administrator in Training (AIT) was informed of the family's concerns but deferred to the Interim DON, who indicated she was handling the situation. The facility's abuse prevention policy requires immediate investigation and notification of the Administrator for any suspected incident, but these steps were not followed. The failure to investigate and report the allegation of neglect constitutes a deficiency in the facility's response to alleged violations.
Failure to Follow Physician Orders and Infection Control for Surgical Site
Penalty
Summary
The facility failed to follow physician admission orders and provide appropriate care for a resident who was admitted after a cerebral vascular accident and craniectomy. The resident had specific physician orders for daily skin checks, use of antiseptic/disinfectant shampoo on the surgical site, wearing a cranium helmet when out of bed, and craniectomy precautions. Upon review, there was no documentation that these orders were implemented. The resident's admission assessment did not note the surgical site, helmet use, or required isolation precautions. The Medication Administration Record and Treatment Administration Record did not include the necessary orders for daily skin checks, helmet use, or antiseptic shampoo. Staff interviews confirmed that the resident was not receiving the ordered care, and the surgical site was not being monitored or cleaned as directed. Observations revealed that the resident's room lacked signage for Enhanced Barrier Precautions (EBP), and there was no accessible personal protective equipment (PPE) or designated disposal bins. Staff, including LPNs and CNAs, were observed providing care and handling the resident's helmet and surgical site without wearing appropriate PPE or following EBP protocols. The resident's helmet, which had openings exposing the scalp, was handled with bare hands, and the surgical site was left uncovered and draining. Staff were unaware of the need for antiseptic shampoo and used standard facility soap instead. There was no communication or documentation of changes in the surgical site, and staff did not report redness or drainage to nursing or medical staff. Family members and medical professionals expressed concerns that the lack of adherence to physician orders and failure to monitor and care for the surgical site led to the development of a Methicillin Susceptible Staphylococcus Aureus (MSSA) infection. This infection required additional medical interventions, including antibiotics, a second hospitalization, and surgical debridement of the scalp. Facility leadership acknowledged that the required orders were not implemented, the surgical site was not assessed or monitored, and EBP was not initiated upon admission. The facility also lacked a wound care program for non-pressure-related wounds, contributing to the failure to provide appropriate care for the resident's surgical site.
Failure to Promptly Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to follow its Grievance Policy by not promptly investigating and resolving a complaint made by a resident regarding an incident during a transfer. The resident, who had significant medical conditions including cerebral infarction, hemiplegia, and dysphagia, was dependent on staff for most activities of daily living. The incident involved the resident's head being bumped during a transfer for a shower, which was reported by the resident's spouse to an LPN. Both the LPN and the DON examined the resident and found no injury, but no further investigation or documentation was completed at that time. The facility's grievance log later documented the complaint, but the investigation and assessment were not initiated until a month after the incident. The Grievance Officer confirmed that the facility did not follow its policy, which requires prompt investigation, communication with the resident, and thorough documentation. There was no evidence of interviews with the resident, staff, or witnesses, nor was there a root cause analysis conducted immediately following the complaint. The lack of timely follow-up and investigation resulted in the facility not meeting its own grievance resolution standards.
Failure to Timely Investigate and Update Care Plan After Resident Accident
Penalty
Summary
The facility failed to timely investigate an accident and update the care plan for a resident who reported her head was bumped during a shower transfer. The resident, who had a history of cerebral infarction, hemiplegia, dysphagia, lack of coordination, and required extensive assistance with activities of daily living, stated that after being assisted into a shower chair by two CNAs, one left the room and the other continued with the shower. The resident reported that her head was bumped when the staff pushed her shower chair too quickly around a bathroom corner, causing significant pain at the site of a previous incision. The incident was reported by the resident's husband to an LPN on the same day, but no investigation or care plan update was documented in the electronic medical record at that time. Interviews with the resident, her husband, and multiple staff members revealed that no one was questioned about the incident until over a month later. The DON confirmed that although the incident was reported, no investigation was initiated because there was no visible injury. The facility's policy required that incident reports be completed promptly and investigations started within 24 hours, with findings and interventions documented and shared with relevant staff. This process was not followed, resulting in a lack of timely investigation and care plan revision after the reported accident.
Failure in Wheelchair Positioning and Equipment Safety Leads to Resident Injury
Penalty
Summary
The facility failed to ensure proper wheelchair positioning and safe equipment use, resulting in a fall and injury for a resident. The resident, who had poor core strength and was undergoing therapy, was found on the floor after falling from a reclining wheelchair that was not fully reclined. This led to a head injury and a hematoma on the left forehead. The Director of Nursing's investigation revealed that the resident's fall was due to the wheelchair not being reclined, which was necessary given the resident's poor core strength. Additionally, the facility failed to maintain safe equipment, as the resident sustained skin tears from sharp bolts under the wheelchair armrests. The Maintenance Director admitted there was no process to ensure wheelchairs were safe before use. Furthermore, the resident, who was designated for a full mechanical lift transfer, was improperly transferred using a sit-to-stand lift by CNAs, contrary to the transfer directive. These failures in supervision and equipment safety contributed to the resident's injuries.
Failure to Adhere to Hair Restraint Policy in Dining Services
Penalty
Summary
The facility failed to ensure that dietary staff adhered to the Dining Services Hair Restraint Policy, which mandates that all staff involved in food preparation, service, and handling must wear appropriate hair restraints at all times. During an observation, a cook was seen wearing a stocking cap that inadequately covered their hair, allowing three inches of gray curly hair to hang loosely beneath the cap. Additionally, the Dining Services Supervisor was observed in the food preparation area without a beard net, leaving their gray facial hair uncovered. These lapses in following the hair restraint policy have the potential to lead to physical contamination of food, food-contact surfaces, and equipment, affecting all 20 residents residing in the facility.
Unsafe Wheelchair Condition Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a wheelchair was in safe operating condition for one resident, which had the potential to affect all 20 residents in the facility. An incident report documented that a resident sustained skin tears on both forearms due to metal bolts with rough edges on the underside of the wheelchair arms. The Assistant Director of Nursing and the Director of Nursing confirmed the presence of sharp bolts on the wheelchair. However, the Director of Nursing was initially unaware of the wheelchair's location. The Maintenance Director stated there was no work order for the wheelchair, and he was also unsure of its location. Later, the Director of Nursing mentioned that they might have found the wheelchair in the physical therapy office, but it was uncertain if it was the same wheelchair that caused the injuries, indicating it could still be in use by other residents.
Failure to Notify Power of Attorney and Physician
Penalty
Summary
The facility failed to immediately notify the Power of Attorney of an injury and did not inform the physician of a significant weight gain for two residents. In the first case, a resident was found with skin tears on both arms at 11:00 AM, but the Power of Attorney was not notified until 5:12 PM. The Director of Nursing confirmed the delay in notification. In the second case, a resident experienced a weight gain of 20.4 pounds over several months, but the physician was not informed of this change. The resident's weight logs and nutrition assessment documented the weight gain, yet there was no record of physician notification. The facility administrator confirmed the oversight in notifying the physician about the weight gain.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prevention and prohibition policy for a resident who was reviewed for abuse. The policy, dated 1/30/23, requires immediate notification to the state agency and an investigation upon receiving an allegation of abuse. However, when the Power of Attorney for the resident reported concerns about potential abuse to the Director of Nursing, the Administrator did not notify the state agency or investigate the allegation. Additionally, the Director of Nursing, who had been working at the facility for a month, had not received the required abuse training, as confirmed by the facility's training records.
Failure to Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency for one resident reviewed for abuse. On February 3, 2025, the Power of Attorney for the resident expressed concern that the resident had been saying, 'Don't hurt me' during care, which was reported to the Director of Nursing. The Administrator acknowledged receiving this allegation on February 1, 2025, but did not notify the state agency. The resident's medical record lacked documentation that the state agency was informed of the abuse allegation.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident. On February 3, 2025, the resident's Power of Attorney expressed concern to the Director of Nursing that the resident had been saying, 'Don't hurt me' during care, suggesting possible abuse. This concern was reported to the Administrator on February 1, 2025. However, the Administrator admitted to not investigating the allegation. The resident's medical record lacked documentation of any investigation following the report of the alleged abuse.
Failure to Revise Resident's Care Plan for Diet Change
Penalty
Summary
The facility failed to revise the care plan for a resident who was on a pureed texture diet with nectar thickened liquids as per a physician's order dated January 24, 2025. On February 3, 2025, it was observed that the resident's water pitcher contained regular water, which was not in accordance with the prescribed diet. The resident's care plan, last revised on January 23, 2025, inaccurately documented that the resident was receiving a mechanically altered texture diet instead of the updated pureed diet. The Care Plan Coordinator admitted on February 6, 2025, that she did not update the care plan to reflect the change in diet when the order was changed.
Failure to Address Opioid-Induced Constipation
Penalty
Summary
The facility failed to develop a care plan addressing potential adverse reactions to opioid medications for a resident with a recent hip fracture, who was receiving Hydrocodone-Acetaminophen. The care plan did not include measures to monitor or prevent constipation, a known side effect of prolonged opioid use. The resident's Medication Administration Record indicated they received the medication twice daily, yet their Bowel and Bladder tracking record showed no bowel movement for six days. Despite the facility having a bowel protocol to address such issues, no interventions were initiated for the resident. Interviews with a Licensed Practical Nurse and a Certified Nursing Assistant confirmed the lack of bowel movements and the absence of any interventions to treat or prevent constipation.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols during incontinence care, which is critical for preventing urinary tract infections. A resident with a history of urinary tract infections was assisted to the toilet by two Certified Nursing Assistants (CNAs). After securing the resident in a mechanical lift and moving them to the bathroom, the CNAs removed their gloves, used hand sanitizer, and applied new gloves. However, one CNA did not change gloves or sanitize hands after cleansing the resident's perineal area and before applying a new incontinence brief. This lapse in infection control practices was acknowledged by the CNA involved, who admitted to not changing gloves before applying the new brief.
Failure to Document Behaviors and Implement Non-Pharmacological Interventions Before Antidepressant Increase
Penalty
Summary
The facility failed to document behaviors and implement non-pharmacological interventions before increasing the dosage of an antidepressant for a resident diagnosed with Dementia, Anxiety, and Insomnia. The facility's policy requires that psychotropic medications be used only after documented behavioral programming with non-pharmacological interventions has been attempted and proven unsuccessful. Additionally, Gradual Dose Reductions (GDR) should be attempted annually unless clinically contraindicated. However, for the resident in question, there was no documentation of behaviors or unsuccessful non-pharmacological interventions prior to the increase in the antidepressant Remeron from 15 mg to 30 mg. Furthermore, there was no attempt or documented declination of a GDR for another antidepressant, Sertraline, within the last year. The resident's medical records, including the Minimum Data Set and Medication Administration Records (MARs), did not document any behaviors or non-pharmacological interventions during the months leading up to the medication increase. The facility's administrators confirmed the lack of documentation for behaviors and non-pharmacological interventions, as well as the absence of a GDR attempt for Sertraline. The increase in Remeron was reportedly due to the resident's poor appetite and crying, as requested by the resident's family, but these behaviors were not documented in the nursing notes as required by the facility's policy.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in several deficiencies. During an observation, it was found that the medication storage room's refrigerator was unlocked and contained two bottles of liquid Lorazepam, a schedule II controlled substance, which were not stored behind double locks as required. Additionally, expired medications, including bisacodyl suppositories and acetaminophen suppositories, were found in the medication storage area. The Licensed Practical Nurse (LPN) on duty confirmed the expiration of these medications and removed them upon discovery, acknowledging that they were unaware of their expired status. The Director of Nursing (DON) verified that the expired medications should have been disposed of and that the medication refrigerator should have been locked. Another deficiency was observed when an Albuterol Sulfate inhaler was found on a bookcase next to a resident's bed. The resident stated that the inhaler was no longer in use and was simply stored there. This was in violation of the facility's medication storage policy, which mandates that medications be kept secure in the medication room or medication cart. The facility's daily census documented 20 residents in the certified unit at the time of the survey.
Failure to Follow Prescribed Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food and liquids in the correct form for a resident with dysphagia, as documented in the hospital discharge records. The resident, who had a stroke, was ordered a pureed diet with nectar thickened liquids and was not to use a straw. However, observations and interviews revealed that the facility did not adhere to these dietary requirements. The resident's Power of Attorney reported that the facility provided regular water with a straw and non-pureed food, such as regular green beans, contrary to the prescribed diet. Further investigation confirmed these discrepancies. The Director of Nursing acknowledged concerns that the resident's diet was not being followed, and the Advanced Nurse Practitioner confirmed that the facility was not adhering to the hospital's diet orders. Observations showed that the resident's water pitcher contained regular water, and a Certified Nursing Assistant confirmed it was not thickened. These actions and inactions led to the deficiency in providing appropriate dietary care for the resident with dysphagia.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The deficiency involves a failure in infection prevention and control practices by staff members at the facility. Specifically, two Certified Nursing Assistants (CNAs), identified as V19 and V20, did not adhere to the facility's hand hygiene policy during the provision of care to residents. On one occasion, V20 failed to remove gloves and perform hand hygiene after providing incontinence care to a resident, R15. Instead, V20 continued to handle various items, including a mechanical lift, remote, linens, and clothing, without changing gloves or sanitizing hands, which could lead to potential cross-contamination. In another instance, V20 was observed carrying a bag of soiled briefs without gloves on one hand and failed to perform hand hygiene after disposing of the bag. V20 then proceeded to calibrate a scale and assist another resident, R8, without changing gloves or sanitizing hands. Additionally, V20 was seen touching his nose, adjusting his mask and glasses, and using a tablet without removing soiled gloves or performing hand hygiene. These actions demonstrate a lack of compliance with the facility's infection control protocols, potentially compromising resident safety.
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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.
Trusted data from CMS and state health departments
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