Crystal Pines Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Crystal Lake, Illinois.
- Location
- 335 North Illinois Avenue, Crystal Lake, Illinois 60014
- CMS Provider Number
- 145257
- Inspections on file
- 38
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Crystal Pines Rehab & Hcc during CMS and state inspections, most recent first.
Two residents were made to feel uncomfortable and disrespected when an agency CNA entered their room without knocking or introducing himself, wore street clothes without a name tag, and interacted inappropriately by touching one resident's head and face. Other CNAs and the administrator confirmed that agency staff sometimes fail to follow dress code and identification protocols, leading to resident complaints.
A resident with dementia and anxiety disorder suffered a large leg laceration requiring sutures after coming into contact with exposed metal on a bed frame during a transfer. The injury was caused by a missing cap on the bed, which had not been previously identified or addressed, and there was no documented policy for routine bed safety checks.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident who had a known history of inappropriate behavior. Despite updates to the care plan and interventions, staff observed the male resident inappropriately touching the female resident in a common area, with her clothing found unbuttoned. The incident was witnessed and reported by a CNA, and the facility's policy requires protection from abuse by anyone.
A resident admitted with a sacral pressure ulcer did not receive a thorough initial or weekly wound assessment, and a baseline care plan was not initiated within the required timeframe. Documentation lacked essential wound details such as measurements, appearance, and drainage, and staff interviews confirmed that facility policy for pressure injury assessment and care planning was not followed.
The facility did not ensure dietary staff were properly trained, as evidenced by the absence of a dietary manager, lack of a training policy, and observed improper dishwashing and hand hygiene practices. Senior staff, rather than a qualified manager, were training new hires, leading to inconsistent and incorrect procedures that could affect all residents.
Staff failed to use the correct scoop size when serving mashed potatoes, providing 2 2/3 ounces instead of the required 4 ounces as specified in the facility's standardized recipes. The correct portion and scoop size information was available but not followed, potentially affecting all residents receiving the meal.
Staff failed to follow safe food handling practices, including handling clean dishes after dirty ones without changing gloves or washing hands, not properly sanitizing kitchenware, storing a soiled scoop inside a flour bin, and leaving beverage pitchers unlabeled and undated in the cooler. These actions created risks of cross-contamination for all residents.
A resident reported missing money after a family visit, suspecting an agency CNA of theft. The facility's investigation involved notifying authorities and interviewing involved parties, but the CNA denied the accusation.
A resident reported that a CNA failed to provide care in a dignified manner by ignoring her pain-related instructions, making a rude comment about her weight, and refusing to identify herself. The resident, who has a history of polyosteoarthritis and obesity, was on isolation for COVID-19. The facility's policy requires staff to wear name tags, but agency staff often do not comply, leading to this incident.
A resident's cell phone was misappropriated by an agency CNA who took it without permission, used it to make personal calls, and downloaded an app. The resident had previously allowed the CNA to use the phone in her presence but denied permission on the day of the incident. The facility's policy prohibits staff from using residents' belongings, and the incident raised concerns about potential access to sensitive information.
A facility failed to provide proper catheter care for two residents, resulting in health complications. One resident's catheter was not changed for over eight months, leading to a hospital admission for sepsis. Another resident's catheter drainage bag was improperly handled, risking infection. The facility's infection control policies were not followed, contributing to these deficiencies.
A facility failed to include interventions in a care plan for a resident's behavior of requesting staff to buy items, despite a history of money handling issues. The resident gave money to a new CNA, who forgot to return it, highlighting a lack of guidance for staff on managing such requests. The administrator noted that CNAs should not perform shopping tasks for residents.
A resident with multiple diagnoses, including spina bifida and major depressive disorder, was subjected to verbal and mental abuse by a CNA who made derogatory comments about the resident's genitalia. The abuse caused significant emotional distress and was reported to the facility's administration after ongoing incidents. Despite a former CNA's intervention, the abuse continued, leading to an Immediate Jeopardy situation.
A resident reported verbal and mental abuse by a CNA, who made derogatory comments about the resident's genitalia. Another CNA witnessed the incident but failed to report it to the Administrator, leading to a delay in addressing the abuse. The facility's policy requires immediate reporting of abuse, which was not followed in this case.
A resident alleged that a CNA pushed him against the wall, causing him to fall. The incident was reported to the head nurse, who dismissed it. Another resident and a CNA corroborated the resident's claims. The Director of Nursing and Assistant Administrator failed to inform the Administrator, who is the abuse coordinator, about the allegation, violating the facility's policy requiring immediate reporting of abuse.
A resident with a high risk of falls and a history of dementia fell from her wheelchair, sustaining a head injury, due to inadequate supervision and missing fall prevention measures. The resident's care plan required an anti-slip mat on her wheelchair, which was not in place at the time of the incident. Staff interviews confirmed the resident's need for close supervision, which was not provided, leading to the fall.
The facility failed to maintain and label oxygen equipment for four residents using oxygen therapy. Observations revealed undated oxygen tubing and humidification bottles, despite physician orders for weekly changes. The facility's policy did not address the frequency of these changes.
A facility failed to administer medications on time for four residents due to a nurse call-in, leading to significant delays. Residents with various medical conditions, including Parkinson's disease and congestive heart failure, received their medications hours after the scheduled times, contrary to the facility's policy of administering within one hour of the scheduled time.
The facility failed to meet the dietary needs of residents by serving inappropriate food options. A resident on Coumadin received spinach despite restrictions, and three residents on puree diets were served food that was not of the required smooth consistency. The dietary manager confirmed these issues, which contradict the facility's policies.
A resident with Moisture Associated Skin Damage did not receive the prescribed wound care treatment. The resident's physician orders included specific instructions for wound care, but during an observation, the wound nurse applied cream without the prescribed calcium alginate dressing, citing unavailability. This resulted in a deficiency in the quality of care provided.
A facility failed to implement pressure-relieving interventions for a resident with a history of pressure injuries. The resident was observed with heels flat on the mattress and against the footboard, contrary to the care plan requiring floating heels and heel protectors. The Wound LPN confirmed the interventions but they were not in place during observations. The facility's policy requires monitoring and modifying interventions, which was not followed.
A resident with spastic hemiplegia and hemiparesis was found with a contracture in the left hand, but the facility failed to assess and implement necessary interventions. The care plan lacked documentation of the contracture, and no restorative therapy was provided, despite the facility's policy to maintain optimal function.
A facility failed to properly position a urinary catheter bag for a resident, leading to potential cross-contamination. The catheter bag was observed full and resting on the floor on multiple occasions, contrary to the facility's policy. An LPN confirmed that catheter bags should not touch the floor, aligning with the facility's guidelines. The resident had a catheter due to obstructive and reflux uropathy.
A facility failed to properly label an enteral nutrition bag for a resident receiving enteral feedings. The bag was missing critical information such as the name of the contents and the start time of the feeding, despite physician orders specifying the administration of Isosource 1.5 via G-tube. A nursing supervisor confirmed the labeling procedure was not followed, which should have included the resident's name, type of formula, date and time prepared, and rate of administration.
Three residents experienced significant medication administration delays, with doses given hours later than scheduled. One resident with multiple health issues, including liver disease, did not receive critical medications on time, leading to frustration and health concerns. Another resident with convulsions received her medications late, and a third resident with Parkinson's Disease also faced delays. The facility's Administrator was unaware of the issue until a grievance was filed, and there was no existing policy on significant medication errors.
A facility failed to ensure staff wore all required PPE while caring for a resident under Enhanced Barrier Precautions. The resident, with multiple medical conditions and open wounds, required enhanced precautions due to a urinary catheter and wound care needs. Despite a posted sign, CNAs provided care without gowns, contrary to facility policy, which mandates gowns and gloves for high-contact activities.
Failure to Ensure Dignity and Respect Due to Unprofessional Conduct by Agency CNA
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the actions of an agency CNA (V3) who provided care to two residents. On the specified date, V3 entered the residents' room without knocking or introducing himself, was not wearing professional attire or a name tag, and interacted with the residents in a manner that made them uncomfortable. One resident reported that V3, whom she had never seen before, was dressed in a black t-shirt with writing and did not announce his role, leading her to feel uneasy about receiving assistance from him. The other resident stated that V3 entered the room without knocking, did not introduce himself, and touched her head and face in a way that made her feel uncomfortable and surprised. She also described the conversation with V3 as inappropriate, as he asked her to guess his age. Interviews with other CNAs and the facility administrator confirmed that agency staff sometimes do not wear scrubs or name tags, and that residents have complained about this lack of professionalism. The administrator acknowledged that all staff, including agency personnel, are expected to wear scrubs, display name tags, and introduce themselves when entering residents' rooms. The failure of V3 to follow these protocols resulted in residents feeling disrespected and uncomfortable during care interactions.
Resident Injury Due to Exposed Bed Frame Hazard
Penalty
Summary
A resident with a diagnosis of senile degeneration of the brain, dementia, and anxiety disorder experienced a significant injury due to a failure by the facility to maintain the resident's bed in a safe condition. During a transfer from wheelchair to bed, assisted by a CNA as per the resident's care plan, the resident sustained a large laceration on the right lateral leg. The injury occurred when the resident's leg came into contact with an exposed area of the bed frame, specifically where a round cap was missing. The wound was severe, requiring emergency room evaluation and 12 sutures, and was accompanied by moderate bleeding and drainage. Staff interviews and record reviews confirmed that the missing bed cap had not been previously identified or reported, and the facility did not have documentation of routine checks to ensure resident beds were free from hazards. The maintenance director only became aware of the missing cap after the incident and replaced it at that time. The absence of a policy or documented procedure for regular inspection of beds contributed to the presence of the hazard that led to the resident's injury.
Failure to Protect Resident from Sexual Abuse by Peer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia and psychosis was not protected from sexual abuse by another resident. The incident took place in the dining room, where a staff member observed a male resident, who was cognitively intact but had a history of inappropriate behavior towards female peers, sitting very close to the female resident and moving his hand back and forth over her lap. Upon intervention, the staff member noticed that the female resident's pants were unbuttoned, and the male resident quickly left the area. The staff immediately reported the incident to the nurse, who then assessed the female resident for harm and notified facility leadership. Prior to this event, the male resident's care plan had been updated multiple times to address his interest in and potential for inappropriate touching of female residents, including the same female resident involved in this incident. Despite these interventions, the incident still occurred, indicating a failure to ensure the safety and protection of the cognitively impaired resident from sexual abuse by another resident. The facility's policy states that all residents have the right to be free from abuse, including abuse by other residents.
Failure to Complete Pressure Ulcer Assessment and Timely Care Plan
Penalty
Summary
The facility failed to perform a thorough pressure ulcer assessment and to initiate a baseline care plan for a resident who was admitted with a pressure ulcer. Upon admission, the resident's assessment noted a pressure area to the sacrum, but there was no further description or measurement of the wound. The electronic medical record and progress notes lacked a detailed initial or weekly assessment of the pressure ulcer, including essential information such as measurements, appearance, wound bed, wound edges, and drainage. The weekly skin check only indicated an open area to the sacrum without further assessment details. Despite physician orders for a wound care consult and wound care to the sacrum, the resident's skin integrity care plan was not initiated until eight days after admission, and the care plan details were incomplete. Interviews with nursing staff and the wound care nurse confirmed that the initial wound assessment was insufficient and did not meet facility policy requirements. Staff acknowledged that a baseline care plan should have been initiated within 24-48 hours of admission and that proper documentation is critical for tracking wound progress and ensuring continuity of care. The facility's own policy required comprehensive documentation of pressure injuries, including wound type, location, stage, measurements, wound bed and edge descriptions, drainage, and pain assessment. However, these requirements were not met for the resident in question, as confirmed by both the Director of Nursing and the wound care nurse, who were unable to locate any detailed wound assessment in the resident's record. This lack of thorough assessment and timely care planning constituted a deficiency in the facility's pressure ulcer care process.
Failure to Ensure Proper Training and Competency of Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff were properly trained, which had the potential to affect all 73 residents. At the time of the survey, the facility did not have a dietary manager, as the previous manager had left two to three weeks prior. Training for new dietary staff was being conducted by more senior workers rather than a qualified dietary manager. The facility also lacked a policy and procedure related to required dietary staff training. Observations revealed that dietary staff were not following proper procedures for hand hygiene and dishwashing, such as not changing gloves between handling dirty and clean dishes and not sanitizing pans for the required amount of time. Interviews with staff indicated confusion and inconsistency regarding proper dishwashing and sanitizing procedures. For example, one dietary aide instructed a new employee to use the sanitizer sink incorrectly and did not ensure that items were sanitized for the appropriate duration. Another staff member confirmed that hands should be washed when moving from dirty to clean dishes, but this was not observed in practice. The facility's own dish machine operation policy requires clean, washed hands to handle clean dishes, but this was not followed during the survey.
Incorrect Scoop Size Used for Mashed Potatoes During Meal Service
Penalty
Summary
The facility failed to ensure that the correct food service scoops were used to serve mashed potatoes, as required by their standardized recipes and portion control guidelines. During meal service, the cook prepared a green handled number 12 scoop, which provides 2 2/3 ounces, for serving mashed potatoes, despite the facility's diet spreadsheet specifying a portion size of 4 ounces. The dietary aide then served one scoop of mashed potatoes to each plate using this incorrect scoop size. The binder listing the correct portion and scoop sizes was available and accessible to staff, but was not referenced or followed during this meal service. Interviews with staff confirmed that menus and recipes, including specified scoop sizes, are to be followed to meet residents' nutritional needs. The facility's policy on standardized recipes also requires adherence to serving sizes for all menu items. At the time of the incident, there were no residents receiving tube feedings or with NPO orders, and the census was 73 residents, all of whom had the potential to be affected by the incorrect portioning of mashed potatoes.
Failure to Follow Safe Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure safe food handling practices, resulting in risks of cross-contamination affecting all 73 residents. Observations revealed that a dietary aide handled dirty dishes and then clean, sanitized dishes without changing gloves or washing hands. Additionally, staff did not follow proper procedures for sanitizing pots, pans, and beverage containers, as items were not submerged in the sanitizer sink for the required amount of time. These actions were inconsistent with the facility's own policies and professional standards for food safety. Further deficiencies included the improper storage of a visibly soiled food service scoop inside a bulk flour bin, directly in contact with the flour, and the presence of multiple unlabeled and undated beverage pitchers in the reach-in cooler. Staff interviews confirmed awareness of the correct procedures, but these were not followed during the survey. No residents were reported to be on tube feedings or NPO status at the time of the survey.
Misappropriation of Resident's Money
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal property. A cognitively intact resident reported that during a family member's visit, they received two twenty-dollar bills, which were placed in the side pocket of their purse. The resident later discovered the money was missing when they attempted to use it for a purchase. The resident and an agency CNA searched the purse and surrounding area but could not locate the money. The incident was reported to the RN Supervisor, who notified the Assistant Administrator and Administrator. The local police and state agency were informed, and an investigation was conducted. The resident believed the agency CNA stole the money, although the CNA denied the accusation. The facility's policy on abuse prevention and prohibition defines misappropriation as the wrongful use of a resident's belongings without consent.
Resident Dignity Compromised by CNA's Actions
Penalty
Summary
The facility failed to provide care to a resident in a dignified manner, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident, identified as R3. R3, who was on isolation for COVID-19, reported that during a care interaction, the CNA did not follow her instructions to avoid causing pain in her knees and made a comment about her weight, which R3 found rude and disrespectful. The CNA also refused to identify herself when asked by R3, which violated the resident's right to know who is providing care. R3's medical history includes polyosteoarthritis, generalized muscle weakness, obesity, and other conditions, and she is cognitively intact. Her care plan indicates she can communicate her pain and needs effectively. Despite this, the CNA did not adhere to R3's requests during care, exacerbating her discomfort and failing to respect her dignity. The incident was reported to the facility's administration, and it was confirmed that the CNA was not wearing a name badge, which is against the facility's policy. Interviews with other staff members, including CNAs and the Director of Nursing, revealed that agency staff frequently do not wear name badges, despite the availability of temporary badges at the facility. The facility's policies require staff to wear name tags at all times to ensure residents can identify their caregivers, emphasizing the importance of treating residents with dignity and respect. The facility's administrator confirmed the incident and stated that the CNA involved would not return to the facility.
Misappropriation of Resident's Cell Phone by Agency CNA
Penalty
Summary
The facility failed to protect a resident's personal belongings from misappropriation, as evidenced by an incident involving a Certified Nursing Assistant (CNA) from an agency. The resident, identified as R2, reported that her cell phone was taken without her permission by the CNA, referred to as V4. R2 had previously allowed V4 to use her phone in her presence, but on the day of the incident, she explicitly denied V4's request to use it. Despite this, V4 took the phone while R2 was napping and used it to make personal calls and download an application related to her agency work. The incident was reported by R2 to the facility staff, who were unable to locate V4 initially. The Registered Nurse (RN), identified as V5, confirmed that V4 admitted to taking the phone and using it in her car. The facility's investigation revealed that V4 did not perceive her actions as wrong, despite being informed by V5 that taking a resident's belongings was unacceptable. The police were involved, and V4 was eventually escorted out of the facility, but not before she attempted to access financial applications on R2's phone, raising concerns about potential misuse of personal information. The facility's policy clearly prohibits the use of residents' personal belongings by staff, and this incident highlighted a breach of that policy. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) expressed disbelief at V4's actions, emphasizing that staff should never use residents' phones for personal reasons. The resident's family member, V18, was particularly concerned about the potential access to sensitive information on the phone, although no financial loss occurred due to password protections. The facility's failure to prevent this misappropriation of property constitutes a deficiency in protecting residents' rights and property.
Inadequate Catheter Care Leads to Health Complications
Penalty
Summary
The facility failed to ensure proper care for residents with urinary catheters, leading to significant health issues. One resident, admitted with multiple diagnoses including obstructive and reflux uropathy, had an indwelling urinary catheter that was not changed for over eight months despite physician orders to change it as needed for blockage or dislodgement. The resident was eventually admitted to the hospital with sepsis, possibly related to the catheter, which was found clogged with sediment and stained orange. The facility's Director of Nursing was unaware of any issues with the catheter, and the nursing staff did not document any catheter changes in the resident's records. Another resident with a catheter due to obstructive uropathy was observed receiving improper catheter care. During a care session, the resident's catheter drainage bag was placed above the bladder level and on the bed, contrary to infection control policies. The resident expressed concern about the risk of infection and discomfort from urine backflow, which was acknowledged by the CNAs providing care. The facility's Director of Nursing confirmed that the drainage bag should always be kept below the bladder level to prevent infection. The facility's Infection Prevention and Control Manual outlines that catheters should be changed based on clinical indications such as infection or obstruction, and drainage bags should be kept below the bladder level. However, these guidelines were not followed, resulting in inadequate catheter care for the residents involved. The lack of adherence to these protocols contributed to the residents' health complications, including a urinary tract infection and potential sepsis.
Failure to Address Resident's Behavior in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident's known behavior of requesting staff to purchase items for her, which was not addressed in her care plan. The resident, who has a history of problems handling money, had previously involved a CNA in purchasing items online, resulting in both getting into trouble. Despite this history, the care plan printed on 11/25/24 did not include interventions for managing this behavior, nor did it provide guidance for staff on how to handle such requests. On 11/25/24, the resident expressed to a CNA her desire for staff to buy things for her, and on 11/27/24, a new CNA reported that the resident had given her money to buy something, which she intended to return but forgot. The facility's administrator confirmed that the resident typically withdraws her monthly funds in one lump sum and often asks staff to shop for her, but noted that CNAs are not appropriate for this task. An abuse investigation dated 11/14/24 revealed that the resident had previously given money to a CNA for snacks, which led to staff education on not accepting money from residents.
Resident Subjected to Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a staff member. The incident involved a Certified Nursing Assistant (CNA) who repeatedly made derogatory comments about the resident's genitalia, escalating to suggesting that it was useless and should be cut off. This behavior caused the resident significant emotional distress, anger, and pain. The resident, who has diagnoses including spina bifida, suicidal ideations, bipolar disorder, major depressive disorder, and anxiety disorder, reported feeling very hurt and angry due to the verbal abuse. The resident initially had a good relationship with the CNA, but over time, the CNA began to make fun of the resident's anatomy, leading to verbal assaults. The resident expressed that these comments were deeply hurtful and caused significant distress, although he initially tried to laugh them off. The resident did not report the incidents earlier due to fear of the CNA losing his job, as the CNA had recently had a baby. The situation was brought to the attention of the Director of Nursing and the Administrator when the resident finally confided in them about the ongoing abuse. A former CNA had overheard the abusive comments and confronted the CNA, who initially dismissed the concern but later agreed to stop. Despite this, the abuse continued, and the resident eventually reported the situation to the facility's administration. The facility's policy on abuse prevention and prohibition clearly states that residents have the right to be free from abuse, including mental abuse, which encompasses humiliation and harassment. The facility's failure to prevent this abuse resulted in an Immediate Jeopardy situation.
Removal Plan
- Took immediate action to protect the resident by suspending the staff member's employment and then terminating the employee from the facility.
- Provided an in-service for all staff regarding abuse education.
- An Emergency Quality Assurance Performance Improvement meeting was held with the interdisciplinary team and medical director.
- The facility conducted twenty-seven interviews of alert and oriented residents with no additional outcomes of abuse.
- The facility initiated and is conducting ongoing audits by interviewing five staff members weekly to ensure compliance.
- The facility is also interviewing three residents weekly to ensure that residents have no concerns with abuse allegations.
Failure to Report Staff-to-Resident Abuse
Penalty
Summary
The facility failed to immediately report an incident of staff-to-resident verbal and mental abuse to the Administrator and local law enforcement. A resident, identified as R8, reported to the Director of Nursing (DON) that a former Certified Nursing Assistant (CNA), V10, had been making derogatory comments about his genitalia. This behavior was confirmed by another CNA, V9, who witnessed the incident and confronted V10, advising him to stop as it constituted sexual harassment. However, V9 did not report the incident to the Administrator, V1, at the time it occurred, and the abuse continued for months without being addressed. The incident was only brought to the attention of the Administrator on 11/7/24, when R8 reported the abuse to the DON, who then informed the Administrator. V9, who had witnessed the abuse, admitted she should have reported it directly to the Administrator but failed to do so. The facility's policy requires immediate reporting of abuse to the Administrator or a designated representative, and law enforcement should be notified within two hours of an allegation. Despite V9's training on abuse reporting, the failure to report the incident promptly resulted in a deficiency in the facility's handling of abuse allegations.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an alleged physical abuse incident involving a resident was immediately reported to the administrator. The incident involved a resident who claimed that a male CNA reprimanded him, pushed him against the wall, and caused him to fall again after he had initially fallen out of his wheelchair. The resident's family member reported the incident to the head nurse, who dismissed the claim. Another resident corroborated hearing the alleged abuse, and a CNA reported that the resident had accused the same CNA of being evil and pushing him. Despite these reports, the Director of Nursing and Assistant Administrator did not inform the Administrator, who is the abuse coordinator, about the allegation of physical abuse. The facility's policy requires that all allegations of abuse be reported immediately to the Administrator, who is responsible for ensuring a thorough investigation. However, the Administrator was only informed of a fall incident and not the specific allegation of abuse. This failure to report and investigate the alleged abuse incident is a deficiency in the facility's adherence to its Abuse Prevention and Prohibition Policy, which mandates immediate reporting and documentation of alleged violations of individual rights.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and fall prevention interventions for a resident identified as high risk for falls, resulting in the resident falling forward out of her wheelchair and sustaining a forehead laceration that required hospital treatment and sutures. The resident, who has a history of repeated falls and diagnoses including dementia, psychosis, and anxiety, was found on the floor of the TV room after attempting to reach for something. Observations revealed that the resident's wheelchair lacked the prescribed anti-slip mat, which was part of her care plan interventions to prevent falls. Interviews with staff indicated that the resident was known to be impulsive, confused, and prone to wandering, requiring close supervision. On the day of the incident, the resident was left unsupervised in the TV room, and her wheelchair was not equipped with the necessary anti-slip mat, which was confirmed to be locked in storage. The facility's fall management policy emphasizes the need for individualized interventions for high-risk residents, but these were not adequately implemented in this case, leading to the resident's fall and injury.
Failure to Maintain and Label Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper maintenance and labeling of oxygen equipment for four residents who were using oxygen therapy. On June 3, 2024, it was observed that Resident 4's oxygen tubing and humidification water bottle were not dated, despite physician orders indicating that these should be changed weekly on the night shift every Sunday for infection control. Similarly, Resident 14 was found with undated nasal cannula tubing and a humidification water bottle dated May 17, 2024, with no physician orders for changing the equipment. Resident 24's oxygen tubing was also undated, although physician orders specified weekly changes. Resident 34 was found with undated oxygen tubing, despite physician orders for weekly changes. The facility's Oxygen Administration Policy, dated January 2017, did not address the frequency of changing oxygen tubing or humidification water bottles.
Medication Administration Delays
Penalty
Summary
The facility failed to administer medications at the prescribed times for four residents, leading to significant delays in medication administration. On June 1, 2024, a nurse call-in resulted in medications being administered late for several residents. Resident 47, who is alert and oriented, reported receiving her morning medications, including Metoprolol Tartrate, Gabapentin, Duloxetine HCL, and Bumetanide, at 2:31 PM instead of the scheduled 9:00 AM. The facility's policy requires medications to be administered within one hour before or after the scheduled time, which was not adhered to in this instance. Resident 70, who has multiple diagnoses including duodenal ulcer, congestive heart failure, and alcoholic cirrhosis of the liver, reported receiving his morning medications at 1:11 PM and 1:12 PM instead of the scheduled 8:00 AM and 9:00 AM. This resident expressed frustration and concern over the delay, particularly because missing his medication to manage ammonia levels could lead to passing out. The facility's administrator was unaware of the issue until a grievance form was submitted by a resident. Resident 28, with diagnoses including osteoarthritis and major depressive disorder, also experienced delays in receiving her medications, with her morning dose of Tizanidine and Dilantin administered at 11:56 AM instead of 9:00 AM. Similarly, Resident 30, who has Parkinson's disease and is non-verbal, received his Rytary medication late, with doses scheduled for 10:30 AM and 2:00 PM administered at 12:30 PM and 3:10 PM, respectively. The facility's policy requires immediate recording of medication administration on the MAR, which was not followed in these cases.
Failure to Meet Dietary Needs of Residents
Penalty
Summary
The facility failed to prepare and serve food according to the dietary needs of its residents, as evidenced by the experiences of four residents. One resident, who was on a regular texture diet with restrictions against green leafy vegetables due to being on Coumadin, reported receiving spinach on her lunch tray. Despite her dietary restrictions being clearly documented, the facility served spinach and broccoli as the only vegetable options, without providing an alternative. The dietary manager acknowledged that residents on Coumadin should receive carrots as an alternative but could not explain why the resident received spinach. Additionally, the facility did not adhere to the required consistency for puree diets for three residents. A test tray revealed that the pureed barbeque hamburger was not smooth and contained small chunks, requiring some chewing. This was confirmed by the dietary manager, who noted that the puree had a gritty texture and should have been smooth. The facility's policies and manuals clearly state that food should be prepared to meet residents' needs, including ensuring pureed foods are of a smooth consistency, similar to moist mashed potatoes or pudding.
Failure to Apply Prescribed Wound Care Treatment
Penalty
Summary
The facility failed to ensure the prescribed treatment was applied to a resident with Moisture Associated Skin Damage (MASD). The resident, identified as R13, had physician orders for wound care on both the left and right gluteal areas, which included cleansing with wound cleanser, patting dry, applying collagen to the wound bed, and covering with a large calcium sheet. However, during an observation, it was noted that the resident's bottom was red, excoriated, and bleeding, with two large dressings in place. When the wound nurse, identified as V4, provided wound care, they applied a cream but did not apply the prescribed calcium alginate dressing, stating they did not have it available. This failure to follow the prescribed treatment regimen was observed during the survey, indicating a deficiency in the quality of care provided to the resident.
Failure to Implement Pressure Relieving Interventions
Penalty
Summary
The facility failed to ensure appropriate pressure-relieving interventions were in place for a resident with a history of pressure injuries. The resident was observed on two occasions lying in bed with his heels flat on the mattress and against the footboard, despite having a care plan that required floating heels and using heel protectors while in bed. The Wound LPN confirmed that the resident was admitted with pressure injuries that had resolved and stated that the interventions included off-loading boots or pillows to keep the heels off the bed. However, these interventions were not observed to be in place during the surveyor's visits. The facility's policy on pressure ulcer prevention emphasizes the need to implement, monitor, and modify interventions to address risk factors, which was not adhered to in this case.
Failure to Assess and Implement Interventions for Resident Contracture
Penalty
Summary
The facility failed to assess and implement interventions for a resident with contractures, specifically for a resident identified as R75. On observation, R75 was found in bed with his left arm and hand flat, showing signs of edema, and his fingers curled towards the palm, indicating a contracture. When asked, R75 was unable to move his left hand. Interviews with staff revealed that there was no restorative therapy being provided for R75's contracture, and the resident was not currently on a physical therapy program. Further investigation showed that R75's care plan did not document the contracture or any interventions for it, despite the resident's diagnoses of spastic hemiplegia and hemiparesis following a cerebral infarction. The Regional Registered Nurse confirmed that there was no assessment of the contracture upon admission, and Occupational Therapy had not evaluated R75's condition. The facility's policy emphasizes the importance of restorative nursing to maintain optimal function, yet this was not applied in R75's case, leading to the deficiency.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure proper positioning of a urinary catheter urine collection bag for a resident, identified as R24, to prevent cross-contamination. During observations on multiple occasions, R24's urinary catheter bag was found full of urine and resting on the floor under the bed. This was noted on two separate days, with the resident confirming that the catheter bag was placed in a privacy bag. A Licensed Practical Nurse (LPN) acknowledged that urinary catheter bags should be placed below the level of the bladder and not on the floor to avoid contamination. The facility's Catheter Care Policy, dated January 2017, specifies that catheter tubing and drainage bags should be kept off the floor. R24 had a physician order for a urinary catheter due to obstructive and reflux uropathy.
Failure to Properly Label Enteral Nutrition Bag
Penalty
Summary
The facility failed to ensure proper labeling of an enteral nutrition bag for a resident receiving enteral feedings. During an observation, it was noted that the resident's feeding pump was running at 70 ml/hr, but the enteral feeding bag was only labeled with the resident's name and a date, lacking the name of the contents and the start time of the feeding. The physician's orders specified the administration of Isosource 1.5 via G-tube at a specific rate and time, but the labeling did not comply with these orders. A nursing supervisor confirmed the procedure for labeling, which should include the resident's name, type of formula, date and time prepared, and rate of administration, was not followed. The facility's policy also required this information to be documented on the formula label, which was not adhered to in this instance.
Medication Administration Delays for Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three residents. Resident 70, who has multiple diagnoses including duodenal ulcer, congestive heart failure, and alcoholic cirrhosis of the liver, reported not receiving his morning medications until 1:00 PM on a Saturday, despite being scheduled for 8:00 AM and 9:00 AM. This delay included critical medications such as rifaximin and lactulose, which are essential for managing his metabolic encephalopathy and liver condition. The delay was attributed to a nurse from an agency, and the resident expressed frustration and concern over the potential health risks of not receiving his medications on time. Similarly, Resident 28, with diagnoses including osteoarthritis and convulsions, received her morning medications late, with her 9:00 AM dose administered at 11:56 AM. This included important medications like dilantin and keppra for convulsions. Resident 30, who has Parkinson's Disease and other conditions, also experienced delays in receiving his scheduled medications, with doses administered hours later than prescribed. The facility's Administrator was unaware of these issues until a grievance was filed, and the Director of Nursing confirmed the absence of a policy regarding significant medication errors.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned all applicable Personal Protective Equipment (PPE) while providing direct care to a resident under Enhanced Barrier Precautions. This deficiency was observed in the case of a resident with multiple diagnoses, including obstructive and reflux uropathy, benign prostatic hyperplasia, peripheral vascular disease, and complete traumatic amputation of both lower legs. The resident had orders for enhanced barrier precautions due to a urinary catheter and wound care needs, which required staff to wear gloves and gowns during high-contact care activities. On a specific date, two Certified Nursing Assistants (CNAs) were observed providing care to the resident without wearing gowns, despite the posted sign indicating the need for Enhanced Barrier Precautions. They transferred the resident, emptied the urinary catheter, and provided incontinence care without the required gown, even though the resident had several open wounds. Another CNA confirmed that staff should wear gowns and gloves when providing direct care to residents on enhanced barrier precautions. The facility's policy on Enhanced Barrier Precautions, although undated, clearly states the need for gowns and gloves during high-contact activities, which was not adhered to in this instance.
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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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