Decatur Rehab & Health Care Ct
Inspection history, citations, penalties and survey trends for this long-term care facility in Decatur, Illinois.
- Location
- 136 South Dipper Lane, Decatur, Illinois 62522
- CMS Provider Number
- 14E848
- Inspections on file
- 44
- Latest survey
- November 13, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Decatur Rehab & Health Care Ct during CMS and state inspections, most recent first.
The facility failed to provide residents and their representatives with adequate notice regarding involuntary transfers or discharges. The initial notification lacked essential information such as appeal rights, Ombudsman contact details, and advocacy agency information. Residents were discharged without proper documentation or communication of required details, affecting those with cognitive and mental health conditions.
The facility failed to document discharge planning for four residents subject to involuntary transfer due to closure. Despite notifying residents and assisting with placement, the facility did not adequately document the discharge planning process in the residents' medical records, violating regulatory requirements.
A resident with a right heel Stage 3 pressure ulcer did not receive adequate care in a facility. The care plan lacked documentation of the ulcer, and weekly skin assessments were not conducted. Treatments were inconsistently applied, and the resident was observed without a heel protector or proper pressure offloading. The facility's policy on pressure ulcer care was not followed, leading to the ulcer's deterioration.
The facility failed to properly label and store medications, affecting all residents. An LPN administered an unlabeled Combivent Inhaler, and the medication refrigerator was found unlocked with unsecured Lorazepam. Additionally, an opened Nystatin powder without a label and undated Azelastine HCL eye drops were found in the medication cart, violating facility policies.
The facility failed to employ a full-time Certified Dietary Manager, affecting all 39 residents. The absence of a Dietary Manager led to issues in the kitchen, such as improper temperature management and incorrect resident meal orders. The kitchen is overseen by the Administrator and Maintenance Director, who acknowledged the lack of guidance and training for new staff.
The facility failed to maintain proper food safety and sanitation practices, affecting all 39 residents. Observations revealed unlabeled and expired food items, inadequate cleaning of kitchen equipment, and insufficient temperature and sanitizer levels in the dishwasher. Despite these issues, dietary staff continued to use the dishwasher and serve expired milk. Interviews with staff highlighted a lack of structured cleaning schedules and oversight, with the Administrator acknowledging the absence of temperature logs and potential health risks.
The facility's antibiotic stewardship policy was found to be inadequate, lacking clear oversight and comprehensive tracking of infections. Multiple residents were prescribed antibiotics for UTIs without documented cultures or organisms, and the infection control logs were not properly maintained. The Regional Clinical Director was overseeing the logs due to the absence of a Director of Nursing, but the facility's program did not include necessary details for effective monitoring.
The facility failed to provide the required minimum square footage for resident bedrooms, affecting all 39 residents. Measurements showed that double occupancy rooms did not meet the 80 square feet per resident requirement, with rooms measuring only 69.19 square feet per resident. A resident expressed dissatisfaction with the cramped conditions, and the Maintenance Director confirmed that none of the rooms met regulatory size requirements.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in documenting anticoagulant use, CPAP usage, and range of motion impairments. An LPN relied on the Assistant Director of Nursing for accurate assessments, resulting in errors. The MDS Nurse confirmed technical issues prevented proper documentation of CPAP use for one resident, while another resident's contracture was not accurately reflected in their MDS.
The facility failed to properly store and secure portable oxygen cylinders for several residents using oxygen. Three cylinders were found unsecured on the floor in the medication storage room, contrary to protocol. The Assistant DON confirmed the cylinders should be secured and stored outside.
The facility failed to administer medications correctly for four residents, resulting in a 19.23% medication error rate. An LPN administered insulin from a mislabeled vial and outside the recommended time frame relative to meals. Residents received medications without having eaten recently, and incorrect insulin dosages were given based on sliding scale orders.
The facility failed to maintain a safe and homelike environment, as evidenced by a resident's broken dresser, another's heavily stained and indented mattress, and poor condition of side rails for a resident with dementia. The Maintenance Director and Housekeeper confirmed these issues, highlighting a lack of timely repairs and replacements.
A resident with cognitive impairments and multiple medical diagnoses reported an allegation of physical abuse, which was not promptly reported to the facility's Administrator or the state agency as required by the facility's policy. The Administrator was unaware of the incident until several days later, highlighting a deficiency in the facility's abuse prevention program.
A facility failed to conduct a Level 2 PASRR for a resident after new diagnoses of unspecified psychosis and anxiety were added. The Business Office Manager, responsible for PASRR coordination, was unaware of the requirement for a Level 2 PASRR following a new mental illness diagnosis. The resident exhibited behaviors such as hallucinations and anxiety, yet no Level 2 PASRR was completed. The facility administrator confirmed the oversight.
The facility failed to develop comprehensive care plans for three residents, resulting in unaddressed medical and nursing needs. One resident's care plan omitted anticoagulant and antipsychotic use and behaviors of self-harm. Another resident's CPAP use was not documented, and a third resident's care plan lacked justification for antipsychotic medication use. The MDSC admitted to incomplete care planning due to limited familiarity with the resident.
A resident with Hemiparesis did not receive necessary restorative care for a contracted left hand, despite being cognitively intact and expressing concerns about the lack of therapy. The Director of Rehab was unaware of the issue until recently, and the Assistant Director of Nursing confirmed that staff should have been performing range of motion exercises. A CNA noted the contracture had been present for at least 1.5 years, highlighting a lapse in care.
A facility failed to obtain necessary medical orders for a resident's CPAP settings and did not maintain proper hygienic care and storage of the CPAP equipment. The resident's CPAP mask and tubing were left uncovered, and there were no documented orders for the CPAP settings. The resident was unsure of the settings and relied on nurses for cleaning. An LPN confirmed the mask should be stored properly, and the administrator acknowledged the lack of documented orders.
The facility failed to manage psychotropic medications properly for three residents, neglecting to attempt Gradual Dose Reductions (GDR), obtain informed consent, and conduct necessary assessments and behavior tracking. One resident with severe cognitive impairment was prescribed multiple psychotropic medications without consent or GDR attempts. Another resident with moderate cognitive impairment and self-harming behaviors received medications without proper documentation or psychiatric services. A third resident was admitted with psychotropic medications but lacked necessary reviews and consents, revealing gaps in the facility's adherence to its policies.
Two residents in the facility were served cold and unpalatable meals, with one resident's pureed meal left uncovered for 55 minutes and another resident's breakfast left for 45 minutes without reheating. The cognitively impaired resident expressed dissatisfaction with the cold food, while the cognitively intact resident reported that her meals are consistently served cold and staff fail to reheat them despite requests. The facility's administrator acknowledged the issue, noting that food should be served warm.
A resident with a history of swallowing difficulties was served a meal that did not meet the physician-ordered pureed diet consistency, leading to coughing and difficulty eating. The kitchen staff, who were new and in training, failed to follow the facility's recipes, resulting in food that was too thin. An LPN noted the inconsistency and expressed concern about the risk of aspiration.
Two residents were not offered necessary influenza and pneumonia vaccinations as per facility policy and CDC guidelines. One resident had no additional pneumonia vaccines documented after receiving PCV13, while another had no vaccination history or offerings documented post-admission. The facility's Infection Preventionist was uncertain about handling unknown vaccination histories.
A resident in a LTC facility was found without a personal call light, requiring him to rely on his roommate for assistance. Despite the resident's care plan indicating a need for supervision due to ADL decline and increased fall risk, the only working call light was attached to the roommate's bed. The Maintenance Director and Administrator acknowledged that residents should not share call lights.
The facility failed to employ a full-time DON, as required to meet resident needs. During a survey, it was confirmed that no DON was present or employed since mid-August, despite the facility's assessment indicating the necessity of a full-time nursing supervisor for the care of 39 residents.
A resident reported disrespectful treatment by staff, including a CNA who mishandled their injured arm and an RN who disregarded their preferences during care. The facility administrator acknowledged the lack of respect in the staff's interactions.
The facility failed to maintain a clean and sanitary environment in a resident room, affecting two residents. One resident reported persistent urine odors and an unclean floor, leading them to leave the facility against medical advice. Observations confirmed a strong ammonia-like odor and sticky, stained floors. The facility administrator acknowledged the issue and noted the resident's preference to change themselves.
A resident admitted with multiple medical conditions did not have a baseline care plan initiated, leading to staff being unaware of the required level of assistance. The resident reported inadequate help and an incident where a CNA mishandled their injured arm. The administrator confirmed the absence of a care plan, which is against the facility's policy.
A facility failed to complete an admission Fall Risk Assessment for a resident with a history of falls and injuries. The resident, who had multiple diagnoses and was not safe to return home, was admitted to gain strength and receive therapy. However, the required assessments were not documented, and therapy was complicated by financial considerations.
The facility failed to report abuse allegations timely to the administrator and SSA for five of six residents reviewed. Instances included delayed reporting of a resident's claim of kissing a housekeeper, a resident's allegation of theft by a former CNA, and a resident's sexually inappropriate behavior towards their roommate. The administrator admitted to not reporting certain incidents to the SSA, believing they had two hours to investigate, leading to further delays.
The facility failed to investigate an allegation of sexual abuse involving four residents. Despite reports of inappropriate sexual urges and comments, the facility did not document or formally investigate the incidents, as required by their Abuse Prevention Program.
The facility failed to care plan and monitor resident behaviors for four residents, including inappropriate sexual behaviors and infatuation with staff. Despite staff awareness, these behaviors were not documented in care plans or behavioral tracking records. The absence of a Care Plan Coordinator since March 2024 contributed to these deficiencies.
A resident with a broken femur experienced significant pain for ten hours due to the facility's failure to provide timely pain control and transfer to the hospital. Despite multiple complaints of pain, the resident received only one dose of Tylenol before being sent to the emergency room at the request of a family member.
A resident with Alzheimer's and severe cognitive impairment fell and fractured his left hip due to inadequate supervision. Despite being at high risk for falls and having a care plan in place, the resident attempted to transfer himself without staff assistance, resulting in a fall in the facility sunroom where staff could not hear him due to television noise.
Inadequate Notification for Resident Transfers
Penalty
Summary
The facility failed to provide adequate notice to residents and their representatives regarding involuntary transfers or discharges, as required by regulations. The written notification dated November 1, 2024, signed by the Administrator, informed residents of the facility's voluntary closure by February 1, 2025. However, this notice lacked essential information such as the right to appeal, contact information for the Ombudsman, and details for advocacy and protection agencies for residents with intellectual/developmental disabilities and mental illness. The facility's closure plan also failed to specify these details, promising only to notify residents and families of relocation and appeal rights once placements were determined. Observations and interviews revealed that the facility began transferring residents as early as November 5, 2024, without providing the required information. On November 13, 2024, the Administrator confirmed that the remaining four residents were discharged without proper documentation of their discharge planning or the required notices. Residents and their families reported receiving verbal and written notifications of the closure, but these did not include the necessary details about transfer dates, discharge locations, or contact information for advocacy and protection agencies. The facility's failure to document and communicate the required information was acknowledged by the Administrator, who admitted to a lack of guidance on what should be documented. The Administrator confirmed that no additional notices were provided beyond the initial letter sent on November 1, 2024, which did not meet regulatory requirements. This oversight affected residents with various cognitive and mental health conditions, including schizoaffective disorder, epilepsy, dementia, and developmental disorders, who were discharged without the necessary support and information.
Failure to Document Discharge Planning for Involuntary Transfers
Penalty
Summary
The facility failed to coordinate and document discharge planning for four residents (R1, R2, R3, R4) who were subject to involuntary transfer due to the facility's closure. The facility's written notification dated 11/1/24 informed residents of the closure scheduled for 2/1/25, and a closure plan was in place to ensure safe and orderly transfers. However, the facility did not adequately document the discharge planning process for these residents, as required by their own policies and procedures. R1, who is cognitively intact and has mental health diagnoses, was informed of the closure and chose to transfer to a sister facility. Despite verbal assurances from staff, there was no comprehensive documentation of discharge planning in R1's medical record, except for a single note by the Maintenance Director. R2, who has severe cognitive impairment, was informed of the closure only a day before the transfer and was unsure of the discharge plan. The facility's staff confirmed R2's transfer to a sister facility but failed to document the discharge planning process in R2's medical record. R3, who is on hospice care and has moderate cognitive impairment, was informed of the closure and chose a facility for transfer. However, there was no documentation of discharge planning in R3's medical record, aside from a note about a discussion with the Maintenance Director. R4, who is cognitively intact, was informed of the closure and chose a facility close to family for transfer. Despite assistance from staff and family involvement, there was no documentation of discharge planning in R4's medical record. The facility's failure to document discharge planning for these residents constitutes a deficiency in meeting regulatory requirements for involuntary transfers.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to adequately assess, monitor, and implement pressure-relieving interventions for a resident with a right heel Stage 3 pressure ulcer. The resident, who was admitted to the facility following a left below-the-knee amputation, did not have any documented skin impairments upon admission. However, the care plan did not include the resident's right heel pressure ulcer, and there was a lack of weekly skin assessments and documentation of the ulcer's condition. The treatment for the ulcer was inconsistently applied, with records showing missed treatments and a lack of adherence to prescribed interventions. The resident's medical record lacked documentation of skin risk assessments since admission, and there were no measurements or weekly assessment details for the right heel ulcer. Observations revealed that the resident was not consistently using a heel protector or having the right foot floated, despite the need for pressure offloading to facilitate healing. The facility's policy on pressure ulcer care was not followed, as the ulcer was not properly documented or included in the care plan, and additional interventions were not established to prevent worsening of the condition. The wound clinic nurse practitioner noted that the resident was motivated to heal and required reminders to offload pressure from the right heel. However, the facility did not provide adequate support to ensure the resident adhered to pressure relief interventions. The administrator acknowledged that the pressure ulcer was facility-acquired and had worsened during the resident's stay, indicating a failure to provide necessary care and interventions to promote healing.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which could potentially affect all 39 residents. An LPN administered a Combivent Inhaler to a resident without a pharmacy label, indicating the resident's name or instructions for use. The LPN acknowledged the absence of the label but identified the inhaler based on the resident's unique prescription. Additionally, the medication refrigerator was found unlocked, containing a bottle of Lorazepam, a controlled substance, and a pharmacy metal box with Lorazepam, which was also unsecured. The Assistant Director of Nursing confirmed that the refrigerator should be locked at all times. Further observations revealed an opened bottle of Nystatin powder in the treatment cart without a label, and the Facility Administrator could not confirm any resident had an order for it. Moreover, the medication cart contained open bottles of Azelastine HCL eye drops for two residents, which were not dated when opened. The facility's policy requires all medications to be labeled with specific information, including the date opened, and controlled substances to be stored under double-lock. These deficiencies highlight lapses in adherence to medication labeling and storage protocols.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager, which has the potential to affect all 39 residents residing in the facility. The Facility Assessment updated on 7/15/24 indicated the need for a Certified Dietary Manager to provide competent support and care for the resident population. However, during the survey conducted from 9/22/24 to 9/25/24, there was no Certified Dietary Manager onsite. Interviews with staff revealed that the absence of a Dietary Manager has led to issues in the kitchen, such as improper temperature management and incorrect resident meal orders. The facility's kitchen is currently overseen by the Administrator and the Maintenance Director, who acknowledged the lack of guidance and training for new kitchen staff and the ongoing struggles in the kitchen operations.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in its kitchen, which could potentially affect all 39 residents. During an inspection, it was observed that the facility's large reach-in freezer and refrigerator contained multiple food items without labels or expiration dates, including frozen potatoes, waffles, deli meat, and various other items. Additionally, the refrigerator contained expired lactose-free milk and improperly stored condiments. The kitchen's air vents were filled with dust and grime, and the range hood was covered in grease, indicating a lack of regular cleaning. The facility also failed to maintain temperature logs for its refrigeration units and dishwasher. The inspection revealed that the dishwasher was not operating at the required temperature, with a recorded wash cycle temperature of only 105 degrees Fahrenheit, below the minimum standard of 120 degrees Fahrenheit. The sanitizer level was also inadequate, as indicated by a litmus strip test showing less than 50 parts per million. Despite these issues, the dietary staff continued to use the dishwasher to clean dishes, which were then used to serve meals to residents. This practice was confirmed by the dietary aide, who acknowledged serving expired lactose-free milk to a resident. Interviews with facility staff, including the Maintenance Director and Administrator, highlighted a lack of structured cleaning schedules and oversight in the kitchen. The Maintenance Director admitted that the kitchen required a deep clean and that the contracted cleaning company only performed a deep clean of the range hood every five years. The Administrator acknowledged the absence of temperature logs and expressed concerns about the potential health risks of serving expired or improperly stored food. The facility's policies on kitchen sanitation and dishwashing were not being followed, contributing to the deficiencies observed during the inspection.
Inadequate Antibiotic Stewardship and Infection Tracking
Penalty
Summary
The facility failed to ensure its antibiotic stewardship policy was comprehensive, which has the potential to affect all 39 residents. The policy lacked documentation on who is responsible for implementation and oversight, what information should be tracked or monitored, the frequency of monitoring, and the infection surveillance tools used to ensure appropriate antibiotic prescription. The facility's infection control logs from May to August 2024 showed multiple instances where residents were prescribed antibiotics for urinary tract infections (UTIs) without listing the organism, despite prompts on the log. This included residents who were prescribed different antibiotics on multiple occasions without documented cultures or infectious organisms. Interviews revealed that the facility's infection control logs were overseen by the Regional Clinical Director due to the absence of a Director of Nursing. The facility claimed to ensure appropriate symptoms for antibiotic usage and that antibiotics were not ordered until cultures were obtained. However, the infection logs did not document UTI cultures and resulting organisms after May 2024, which was confirmed as part of surveillance monitoring for infection control and antibiotic stewardship. The facility's Antibiotic Stewardship Program was confirmed to be lacking in comprehensiveness, including oversight responsibilities, information review, frequency, and the use of infection assessment tools.
Inadequate Room Size for Residents
Penalty
Summary
The facility failed to provide the required minimum square footage of floor space for each resident in their bedrooms, affecting all 39 residents. Historical documentation and actual measurements revealed that the double occupancy rooms did not meet the minimum requirement of 80 square feet per resident, with rooms measuring only 69.19 square feet per resident. This deficiency was observed in multiple rooms, including those currently used as the Nursing Director's office and therapy room. During the survey, a resident expressed dissatisfaction with the cramped conditions, stating that the limited space made it difficult to store personal items and maneuver a wheelchair. The Maintenance Director confirmed that none of the rooms met the regulatory size requirements, acknowledging resident complaints but indicating a lack of feasible solutions.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to accurately complete resident assessments for four residents, leading to discrepancies in their Minimum Data Sets (MDS). One resident's MDS incorrectly documented antiplatelet use instead of anticoagulant, despite the resident receiving Xarelto, an anticoagulant, daily. The MDS Coordinator, who floats between three facilities, relies on the Assistant Director of Nursing to complete assessments, which resulted in this error. Another resident's MDS did not document the use of a CPAP machine or the resident's pulmonary disease, even though the resident uses the CPAP every night and has a diagnosis of Obstructive Sleep Apnea. The MDS Coordinator confirmed the oversight. Additionally, a third resident's MDS did not indicate the use of a CPAP machine, despite the resident having a CPAP machine in their room and a physician's order for its use. The MDS Nurse confirmed the CPAP was not coded on the MDS due to technical issues. Lastly, a resident with a diagnosis of Hemiparesis was observed with a contracted left hand, yet their MDS inaccurately documented full range of motion in the left hand. The Director of Rehab and a Certified Nursing Assistant confirmed the contracture, highlighting the inaccuracy in the resident's assessments.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to appropriately store and secure portable oxygen cylinders for five residents who were using oxygen. During an observation, three oxygen cylinders were found sitting unsecured on the floor in the medication storage room, which is against the facility's protocol. Additionally, three oxygen carts containing three oxygen cylinders each were also present in the room. The Assistant Director of Nursing confirmed that the oxygen cylinders were not secured in a cart as required and acknowledged that oxygen cylinders should not be stored in the medication storage room but rather outside. The facility's Residents On Oxygen form documented that the residents involved were using oxygen.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders and manufacturer recommendations for four residents. For Resident 13, the LPN administered insulin from a vial labeled for another resident and not within the recommended time frame relative to meals. The resident's glucose level was checked, and insulin was administered without ensuring the resident had eaten recently, as the resident had last eaten at 8:30 AM and was waiting for lunch at 12:21 PM. Resident 24 was administered Ferrous Sulfate without having eaten recently, as the resident was waiting for lunch and had last eaten at breakfast. For Resident 90, the LPN administered an incorrect dosage of insulin based on the sliding scale order and not within the recommended time frame relative to meals. Similarly, Resident 31 received insulin not within the recommended time frame relative to meals, as the resident had not eaten since breakfast and was waiting for lunch. The facility's medication administration practices resulted in a medication error rate of 19.23 percent, significantly exceeding the acceptable rate of less than 5 percent.
Deficiencies in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. One resident reported that his dresser was broken and missing the front of the top drawer, making it difficult for him to access his belongings. Despite notifying the staff a week prior, the issue remained unresolved. The Maintenance Director confirmed the dresser should be in good working repair. Another resident's mattress was found to be heavily stained and indented, with the housekeeper acknowledging the stains were permanent and expressing concern about the condition of many mattresses in the facility. Additionally, a resident with diagnoses including Unspecified Dementia and Cerebral Infarction was found to have side rails in poor condition, with foam that was ripped and tape that was shredded and frayed. The resident was observed in distress, shaking the side rail and calling for assistance. The Maintenance Supervisor confirmed the poor condition of the side rails and mentioned having replacement materials available. These observations indicate a failure to ensure equipment is in good repair and the environment is clean and free of debris, compromising the residents' right to a safe and comfortable living space.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident, identified as R4, to the Abuse Coordinator. The facility's policy mandates that all allegations of abuse must be reported immediately to the Administrator and to the Illinois Department of Public Health (IDPH) within 24 hours of forming the suspicion. However, in this case, the Administrator was not informed of the allegation, and the report to the state agency was delayed. R4, who has medical diagnoses including Psychotic and Mood Disturbance, Anxiety, Congestive Heart Failure, Bipolar Disorder, Dementia with Agitation, Schizophrenia, and Weakness, reported that someone named '[NAME]' cut her private parts. The facility did not have any resident or staff member by that name, and the staff assessed R4 with no findings but failed to report the incident to the Administrator. R4's Minimum Data Set (MDS) indicated moderate cognitive impairment and required moderate assistance with daily activities. Despite R4's complaint documented in a nurse progress note, the Administrator was unaware of the incident until several days later. The Administrator acknowledged the oversight and stated that the report to the state agency would be made immediately. The failure to report the allegation promptly as per the facility's policy constitutes a deficiency in the facility's abuse prevention program.
Failure to Conduct Level 2 PASRR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to obtain a Level 2 Preadmission Screening and Resident Review (PASRR) for a resident after a new diagnosis of mental illness. The resident, identified as R30, was admitted to the facility with no initial mental illness diagnosis, as documented in a PASRR Level 1 Screen Outcome dated August 16, 2022. However, subsequent diagnoses of unspecified psychosis and anxiety were added on October 10, 2023, and October 18, 2023, respectively. Despite these new diagnoses, a Level 2 PASRR was not completed. The Business Office Manager, responsible for coordinating PASRRs, was unaware that a Level 2 PASRR was required after a new diagnosis of mental illness. Additionally, a Licensed Practical Nurse noted that the resident had a history of behaviors such as hallucinations and yelling, and experienced paranoia and anxiety, yet no Level 2 PASRR was conducted. The facility administrator confirmed the oversight, acknowledging the lack of awareness regarding the requirement for a Level 2 PASRR following a new mental illness diagnosis.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and nursing needs. For one resident, the care plan did not include the use of anticoagulant and antipsychotic medications, nor did it address behaviors of self-harm and fixation on medications, despite multiple documented incidents of anxiety and verbal outbursts. The facility administrator acknowledged that these aspects should have been included in the care plan. Another resident's care plan failed to document the use of a CPAP machine, which the resident used independently every night. The resident was unsure of the machine's settings, and the care plan did not reflect the responsibility of the nursing staff to clean the CPAP equipment weekly. Additionally, a third resident's care plan lacked specific behaviors justifying the use of antipsychotic medication, appropriate diagnoses, and non-pharmacological interventions. The Minimum Data Set Coordinator admitted that the comprehensive care plan was not completed within the required timeline and was only basic due to limited familiarity with the resident.
Failure to Provide Restorative Care for Resident's Contracted Hand
Penalty
Summary
The facility failed to provide appropriate restorative care services for a resident diagnosed with Hemiparesis, as evidenced by the lack of range of motion exercises for the resident's contracted left hand. The resident, who had moderately impaired cognition initially and later was documented as cognitively intact, did not receive any therapy or restorative services for his left hand, despite having a contracture that developed over the past few months. The resident expressed concerns about the lack of therapy or exercises for his hand, which he noticed had become contracted recently. The Director of Rehab confirmed the contracture and stated that she was unaware of the issue until recently and was waiting for therapy orders to be signed. She also mentioned that the previous therapy company did not provide records, leaving uncertainty about past services. A Certified Nursing Assistant noted that the resident's hand had been contracted for at least 1.5 years and that attempts to open the hand during ADLs were unsuccessful. The Assistant Director of Nursing confirmed that staff should have been performing range of motion exercises on the resident's left hand, indicating a lapse in the facility's restorative care services.
Failure to Obtain CPAP Orders and Maintain Equipment Hygiene
Penalty
Summary
The facility failed to obtain necessary medical orders for a resident's Continuous Positive Airway Pressure (CPAP) settings and did not maintain proper hygienic care and storage of the CPAP equipment. The facility's policy requires specific orders for CPAP use, including unit type, pressure settings, and cleaning protocols. However, observations revealed that the resident's CPAP mask and tubing were left uncovered on the nightstand, and there were no documented orders for the CPAP settings or airway pressure. The resident, who uses the CPAP independently, was unsure of the settings and relied on nurses for cleaning. A Licensed Practical Nurse confirmed that the CPAP mask should be stored in a clear plastic bag when not in use, and the facility administrator acknowledged the lack of documented settings and airway pressure orders.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to its Psychotropic Medication Policy, resulting in deficiencies related to the management of psychotropic medications for three residents. The policy mandates the implementation of Gradual Dose Reductions (GDR), obtaining informed consent, and conducting thorough assessments and behavior tracking for residents on psychotropic medications. However, the facility did not attempt GDRs for the medications of residents R21, R35, and R37, nor did it document any clinical contraindications for not doing so. Additionally, the facility failed to obtain necessary consents for the psychotropic medications administered to these residents. Resident R21, who has severe cognitive impairment and a history of verbal behaviors, was prescribed multiple psychotropic medications, including Risperidone and Mirtazapine, without documented consent or attempts at GDRs. The facility's records lacked documentation of pharmacy recommendations being followed up with the physician, and the pharmacy consultation reports were incomplete. Similarly, Resident R35, with moderate cognitive impairment and a history of self-harm and fixation on medications, was administered several psychotropic medications without documented consents or assessments. The behavior tracking for R35 did not accurately reflect the resident's behaviors, and the facility failed to ensure psychiatric services were provided. Resident R37 was admitted with orders for psychotropic medications, but the facility did not complete psychotropic drug reviews upon admission, as required by their policy. The medical record for R37 lacked consents for the medications and did not provide justification for the decline of a GDR. The facility administrator admitted to not being aware of the requirement for psychotropic drug reviews on admission, highlighting a gap in the facility's adherence to its own policies and procedures.
Failure to Serve Palatable and Warm Food
Penalty
Summary
The facility failed to provide palatable and appropriately heated food to two residents, R14 and R22, as observed during the survey. R14, who is moderately cognitively impaired, was served a pureed meal that was left uncovered on the counter for 55 minutes before being served. The meal, consisting of blended pot roast, beets, and breadsticks, was described as lacking flavor and requiring mechanical chewing, with the resident expressing dissatisfaction with the cold temperature of the food. R22, who is cognitively intact and requires setup assistance for eating, reported that her meals are consistently served cold. On the day of observation, her breakfast tray was left in front of her for 45 minutes without being reheated, despite her requests. The resident expressed dissatisfaction with the cold oatmeal and noted that staff often fail to return to reheat her food. The facility's administrator acknowledged the issue, noting that food should be served warm and that staff might forget to reheat meals due to being busy.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to adhere to a physician's order to provide a pureed diet for a resident, identified as R14, who was moderately cognitively impaired and had a history of difficulty swallowing. The resident's physician order sheet documented a requirement for a carbohydrate-controlled diet of pureed texture and thin liquids. However, during meal preparation, the kitchen staff did not follow the facility's recipes for pureed foods, resulting in a meal that was not of the appropriate consistency. The pot roast and vegetables were prepared with an incorrect amount of water, leading to a pourable consistency with bits of meat, while the beets were overly watery. This inconsistency in food texture was observed during the resident's meal, where R14 struggled to eat, spilling food and coughing due to the thin consistency. The LPN attending to R14 noted the resident's difficulty with the meal and acknowledged the inconsistency in food preparation, highlighting previous issues with food being too thick. The LPN expressed concern about the potential for aspiration if the food consistency was not corrected. The facility administrator confirmed that the kitchen staff was new and undergoing training, acknowledging the risk of aspiration and pneumonia if the resident's meals were not prepared to the correct pureed consistency. The facility's policy on therapeutic and mechanically altered diets emphasized the importance of preparing and serving diets as planned, which was not adhered to in this instance.
Failure to Document and Offer Vaccinations
Penalty
Summary
The facility failed to maintain proper documentation and offer necessary vaccinations for influenza and pneumonia to two residents, R30 and R35, as per their own policy and CDC guidelines. R30's records indicate that they received the Pneumococcal Conjugate Vaccine 13 in August 2022, but there is no documentation of any additional pneumonia vaccines being offered thereafter. This oversight left R30 not up to date on pneumonia vaccinations, contrary to the facility's policy which mandates offering the pneumonia vaccine within 30 days of admission and following the Pneumonia Vaccination Timing Guidelines. R35's case highlights a lack of documentation and follow-up regarding vaccination history and offerings. Upon admission, R35's medical records did not contain any documentation of influenza or pneumonia vaccination history, and there was no evidence that these vaccinations were offered post-admission. Despite R35's expressed desire to receive these vaccinations, the facility was unable to obtain vaccination history due to a lack of information from the previous group home and the absence of family to consult. The facility's Infection Preventionist, V1, expressed uncertainty about handling situations where vaccination history is unknown, which contributed to the deficiency.
Deficiency in Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide an accessible working call light for a resident, identified as R25, who was part of a sample of 34 residents reviewed for call light accessibility. R25's care plan, last revised in May 2024, indicated a need for supervision with Activities of Daily Living (ADLs) and noted a decline in ADLs and increased fall risk by August 2024, warranting referrals for physical and occupational therapy. On September 23, 2024, R25 reported not having a personal call light in his room, requiring him to wake his roommate, R90, to request assistance at night. Observations confirmed that the only working call light was attached to R90's bed, leaving R25 without direct access. The Maintenance Director, V5, acknowledged that residents should not be without a call light, and the Administrator, V1, confirmed that residents should not share call lights.
Failure to Employ Full-Time Director of Nurses
Penalty
Summary
The facility failed to employ a Registered Nurse to serve as a full-time Director of Nurses (DON), which is a requirement to meet the needs of the residents. This deficiency was identified during a survey conducted from September 18 to September 24, 2024. During the survey, it was observed that there was no DON present or employed by the facility. The facility's administrator confirmed on September 20, 2024, that there has not been a full-time DON employed since August 15, 2024. The facility's assessment documents indicate that a full-time nursing supervisor is necessary to provide competent support and care for the 39 residents currently residing in the facility.
Resident Dignity and Respect Deficiency
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by the interactions between the resident and the staff. The resident, who was admitted after suffering a broken knee cap and arm, reported that a CNA was unaware of the extent of their injuries and pulled the resident's right arm despite being informed of the fracture. The resident described the CNA as uncaring and rude. Additionally, a progress note documented an RN instructing the resident on how to transfer to a bedpan, emphasizing adherence to doctor's orders over the resident's preferences. The RN acknowledged the resident's desire to leave the facility, which the resident later described as 'lying' during a phone call. The facility administrator reviewed the progress note and agreed that it was not respectful.
Failure to Maintain Clean and Sanitary Resident Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in a resident room, affecting two residents. One resident reported that their roommate frequently urinated on the bed, causing a persistent bad odor, and the facility did not clean the floor, which was covered in urine. The resident left the facility against medical advice due to these conditions. Observations confirmed that the room was cluttered, had a strong ammonia-like odor, and the floor was sticky and stained with a yellow-brown substance. The roommate, who was cognitively intact and frequently incontinent of urine, was observed to have the same odor as the room. The facility administrator acknowledged the issue, noting the resident's preference to change themselves and the need for floor cleaning.
Failure to Initiate Baseline Care Plan for Resident
Penalty
Summary
The facility failed to initiate a baseline care plan and resident-centered interventions for a resident who was admitted with multiple medical conditions, including chronic anemia, chronic depression, frequent falls, and fractures. The resident was admitted to the facility on August 7, 2024, and left against medical advice on August 13, 2024. During this time, there was no documentation of a baseline care plan or specific interventions tailored to the resident's needs, which is a requirement according to the facility's policy revised on November 1, 2017. The lack of a baseline care plan resulted in the staff being unaware of the level of assistance the resident required. The resident reported that the CNAs were not informed about the extent of help needed, leading to an incident where a CNA pulled the resident's right arm, which had been broken. The administrator confirmed that without a care plan, the staff would not have been aware of the necessary assistance for the resident.
Failure to Conduct Admission Fall Risk Assessment
Penalty
Summary
The facility failed to complete an admission Fall Risk Assessment for a resident with a history of falls and injuries. This deficiency was identified during a review of three residents, where one resident was affected. The facility's policy on Fall Prevention, revised on 11/10/18, mandates that fall assessments be conducted on the day of admission, quarterly, and with any change in condition. However, the admission nurse did not complete the required fall risk assessment or any other baseline assessment for the resident upon admission. The resident in question had multiple diagnoses, including chronic anemia, chronic depression, frequent falls, and a history of fractures. The resident was admitted to the facility after being discharged from a hospital, where it was determined that they were not safe to return home. The resident expressed that they expected to receive therapy at the facility, which did not occur. The facility administrator acknowledged the lack of documentation for the admission fall risk assessment and complete admission assessment, noting that the resident was admitted to gain strength and receive therapy, which was complicated by financial considerations related to therapy co-pays.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report abuse allegations timely to the administrator and the State Survey Agency (SSA) for five of six residents reviewed for abuse. The facility's Abuse Prevention Program mandates immediate reporting of any potential or alleged mistreatment, neglect, and abuse to a supervisor and the administrator, and further reporting to the SSA within specified timeframes. However, multiple instances were identified where this protocol was not followed, leading to delayed reporting and investigation of abuse allegations involving residents and staff members. One instance involved a resident who reported to a Licensed Practical Nurse (LPN) that they had kissed a housekeeper. The resident later mentioned cuddling with the housekeeper during an assessment interview, but this was not reported to the administrator until the following day. Another case involved a resident who alleged that a former Certified Nursing Assistant (CNA) had stolen $40 from them. The resident reported this to another CNA, who failed to report the allegation to the administrator until several months later. Additionally, there were reports of a resident exhibiting sexually inappropriate behavior towards their roommate and other residents, which were not documented in the facility's Abuse Log or reported to the SSA. The facility's administrator acknowledged that staff are required to report abuse allegations immediately but admitted to not reporting certain incidents to the SSA. The administrator believed they had two hours to investigate and determine if an incident needed to be reported, which led to further delays. Interviews with staff and residents revealed inconsistencies in the reporting and documentation of abuse allegations, highlighting a significant lapse in the facility's adherence to its Abuse Prevention Program and state reporting requirements.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving four residents. The facility's Abuse Prevention Program requires immediate reporting and investigation of any potential or alleged instances of mistreatment and abuse. However, the facility did not follow this protocol. One resident, who is cognitively intact, was reported to have inappropriate sexual urges towards another male resident. Despite these reports, the facility did not document any abuse allegations involving this resident in their Abuse Log for March or April 2024. Interviews with staff and residents revealed that the incidents were known but not formally investigated or documented as required by the facility's policy. The Administrator in Training (V1) admitted to being aware of the sexual urges and comments made by the resident but did not conduct a formal investigation, believing the information was based on hearsay. The administrator also misunderstood the requirement for immediate reporting and investigation, thinking there was a two-hour window to determine if an incident needed to be reported. This lack of proper investigation and documentation led to a failure in addressing the alleged sexual abuse, as required by the facility's Abuse Prevention Program.
Failure to Care Plan and Monitor Resident Behaviors
Penalty
Summary
The facility failed to care plan resident behaviors, develop behavioral interventions, and monitor behaviors for four residents. One resident with moderate cognitive impairment reported kissing a housekeeper and making inappropriate comments and actions towards staff. Despite these behaviors, the resident's care plan and behavioral tracking records did not include interventions to address these behaviors. Interviews with staff revealed that the resident was infatuated with the housekeeper and had been instructed to give the housekeeper space, but these instructions were not documented in the care plan or behavioral tracking records. Another resident, who is cognitively intact, exhibited inappropriate sexual behaviors towards other residents. This resident expressed a desire to move to a facility with more women for sexual intercourse and made inappropriate comments and actions towards a male roommate. The roommate was moved to another room due to discomfort, but the resident's care plan and behavioral tracking records did not include interventions to address these sexual behaviors. Staff interviews confirmed that the resident had made sexual comments and exhibited inappropriate behaviors, but these were not documented in the care plan. The facility has not had a Care Plan Coordinator since March 2024, and the responsibility for implementing behavior tracking forms falls on the Care Plan Coordinator and the Social Services Director. The lack of a Care Plan Coordinator has contributed to the failure to document and address resident behaviors appropriately. The Social Services Director and other staff members were often the last to be informed of resident behaviors, leading to a lack of timely and effective interventions.
Failure to Provide Timely Pain Control and Hospital Transfer
Penalty
Summary
The facility failed to provide timely pain control and transfer to the hospital for a resident with a broken femur. The resident, who had a history of Alzheimer's Disease, Dementia, and other chronic conditions, was found on the floor in the facility sunroom. Despite the resident's complaints of severe pain and inability to straighten his left leg, the staff delayed transferring him to the hospital for ten hours. During this period, the resident was given only one dose of Tylenol and continued to experience significant pain. The resident's progress notes document multiple instances where the resident was in pain and the staff's inadequate response. The resident was eventually sent to the emergency room at the request of a family member. The medical director confirmed that the pain could have been controlled and hours of pain prevented if the resident had been sent to the hospital sooner. The facility's pain policy emphasizes the importance of assessing and managing pain to enhance the quality of life, which was not adhered to in this case.
Failure to Prevent Falls in High-Risk Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent falls with injury for one resident (R1) who was at high risk for falls. R1, who had multiple diagnoses including Alzheimer's Disease, Dementia, and a history of falls, was found on the floor in the facility sunroom in front of his wheelchair. Despite being severely cognitively impaired and having a care plan that included reminders to lock wheelchair brakes and keep the call light within reach, R1 attempted to transfer himself without staff supervision, resulting in a fall that caused a fractured left hip and a subdural hematoma. Interviews with staff revealed that R1 frequently tried to stand up from his wheelchair due to his dementia and lack of safety awareness. Staff members acknowledged that R1 needed to be kept in supervised areas while up in his wheelchair, but on the night of the fall, R1 was not within view of the staff. The incident occurred in the sunroom where the television noise prevented staff from hearing R1's movements, leading to inadequate supervision and ultimately, the fall and injury.
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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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