El Paso Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Illinois.
- Location
- 850 East Second Street, El Paso, Illinois 61738
- CMS Provider Number
- 146097
- Inspections on file
- 61
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at El Paso Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident was subjected to nonconsensual sexual contact by another resident in a common area, as witnessed by staff and confirmed by both residents involved. The incident was reported and documented, with the affected resident stating the contact was unwanted and made her uncomfortable. Facility policy prohibits such abuse, but the event occurred despite these guidelines.
A resident with mental health concerns was transferred to the hospital due to behavioral issues and later returned to the facility in an agitated state. The facility did not notify the resident's guardian of the return, despite policy requiring such notification, and the guardian only became aware after reaching out to the facility.
A resident identified as an elopement risk made multiple attempts to leave the facility unattended, including one incident where the resident exited into the parking lot and became combative. Despite these events, the care plan was not updated or revised to include new interventions, as confirmed by the Care Plan Coordinator.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents according to their care plans.
A resident with multiple medical and psychiatric diagnoses was transferred to the hospital without completion of the required SBAR assessment or documentation of a provider order, as mandated by facility policy. Staff interviews confirmed the absence of necessary documentation and uncertainty about policy requirements for hospital transfers.
A resident with severe cognitive impairment and a history of aggression struck another cognitively intact resident on the head during a verbal altercation in a common area. The incident was witnessed by another resident and confirmed by an LPN, and occurred despite facility policies requiring close supervision for residents identified as moderate risk for behavioral issues.
Two residents with histories of behavioral issues were involved in a physical altercation in the dining room, resulting in one resident being struck in the mouth and bleeding. Despite one-to-one monitoring and multiple staff present, the aggressive resident was able to hit both another resident and staff members. The incident was witnessed by several staff, and the facility's investigation lacked comprehensive witness details.
The facility did not complete thorough abuse investigations for three residents, failing to identify and interview all potential witnesses and relying on generic interview forms that did not address the specific details of the alleged incidents. In one case, a physical altercation between two residents was not fully investigated, and in another, an allegation of verbal abuse by a consultant was not explored in detail. Staff confirmed that original statements were not retained and that the process lacked targeted questioning.
A resident with a history of physical aggression and multiple psychiatric diagnoses was left unsupervised in his room with the door closed, despite being on 1:1 supervision status. The CNA assigned to supervise him was assisting another resident at the time, leaving the resident out of sight, contrary to facility in-service requirements that mandate continuous observation.
A resident with an indwelling urinary catheter was found with the catheter tubing unsecured and hanging out of an incontinent brief, contrary to facility policy requiring the use of a leg strap. The resident expressed concern about the tubing not being strapped, and both a CNA and the ADON confirmed that a stabilizer should have been in place.
A facility failed to protect residents' health information when a group text message containing dietary information cards with residents' names, room numbers, and diet details was shared among CNAs. Despite the facility's policy on PHI protection, this incident violated HIPAA regulations. The Administrator was aware of the issue but could not initially find proof, while the DON confirmed the breach as a HIPAA violation. Residents expressed concerns about their privacy.
Two residents experienced physical abuse from fellow residents in separate incidents. One resident was pushed against a wall after asking another to stay out of her room, while another was pushed in the dining room following a disagreement over meal tickets. Both residents were cognitively intact, and the incidents were reported to the state agency.
The facility failed to maintain a homelike environment, with issues such as chipped paint, holes in walls, and loose cable cords observed in several resident rooms. The maintenance supervisor was unaware of many issues until the survey, and work orders were not adequately documented or addressed. Residents expressed dissatisfaction with their living conditions, which were not promptly addressed by the facility.
The facility failed to process medication orders timely, resulting in six residents not receiving prescribed medications. The Psychiatric Nurse Practitioner entered orders into the EMR, but they remained pending until confirmed by an LPN, who was unavailable to do so promptly. This led to missed doses of medications for residents with conditions such as schizophrenia, depression, and anxiety.
The facility failed to maintain privacy and dignity for two residents. One resident's room door would not latch, preventing privacy, and the issue was known but unresolved. Another resident's urinary catheter bag was exposed in the dining room, contrary to her care plan, and the facility lacked a policy for covering catheter bags.
The facility failed to accommodate the needs of two residents by placing activity calendars too high and in small print, making them inaccessible. One resident, blind in one eye, missed activities due to this oversight. The DON confirmed the calendars were not appropriately placed or legible.
A facility failed to include a resident's Hepatitis C and blindness in the right eye in their care plan. The resident, observed in a wheelchair with a cloudy right eye, confirmed blindness. The face sheet documented these diagnoses, but the care plan did not address them. The care plan coordinator acknowledged the oversight.
A facility failed to implement nonpharmacological interventions for a resident with depression and anxiety, despite documented verbal and physical behaviors. The facility's policy requires such interventions, but the resident's care plan lacked them, and the DON confirmed their absence, stating the resident was only on antidepressants.
A facility failed to have a signed hospice contract for a resident receiving hospice services. The resident, with a terminal diagnosis related to dementia, had an order for hospice evaluation and treatment. Communication with the resident's POA and the local hospice was documented, and the resident was approved for hospice services. However, during a survey, the facility could not provide a signed hospice contract, as confirmed by the Administrator.
The facility's survey book was not up-to-date, missing the most recent survey and several complaint investigations from 2024. This was confirmed by the administrator and could potentially affect all 88 residents.
The facility failed to maintain the required minimum of three years of resident grievance records, only having records for 2023 and 2024. The Director of Nursing and Administrator confirmed the absence of 2022 records, which could affect all 88 residents.
The facility failed to maintain a proper bookkeeping system for resident accounts, affecting all 93 residents. The electronic ledger system was hacked, and manual ledgers were not adequately maintained. The Administrator could not provide current balances, and the last balance report was from September 2023. V4 struggled to keep up with manual processes, and required documentation was not submitted to the corporate office since September 2023.
A resident was physically abused by another resident who pulled her hair and pushed her head down after being asked to stop tampering with diet cards. The facility's investigation confirmed the abuse, but the motive remained unclear as both residents refused to discuss the incident further.
A resident with severe mental health issues, including Bipolar disorder and Generalized Anxiety, was involuntarily discharged without a signed physician order, despite a history of aggressive behaviors and elopement attempts. The facility failed to ensure proper documentation and compliance with discharge procedures, leading to a deficiency in handling the resident's discharge.
A resident with mental health disorders did not receive required social services, including one-on-one visits and group therapies, during their stay. The facility's social services department was newly established and lacked in-house psychiatric services, contributing to the deficiency.
The facility failed to employ a Certified Dietary Manager, affecting all 95 residents. The current Dietary Manager is not certified and has not been enrolled in a certification program. They do not perform clinical nutrition tasks, such as reviewing weight records or completing the MDS section, as they are often filling in for absent staff. This deficiency was noted in the facility's application for Medicare and Medicaid.
The facility failed to provide adequate staffing in the Dietary Department, resulting in delayed meal services for all 95 residents. The Facility Assessment indicated a need for 900 to 945 hours of staffing per two-week period, but only 301.25 hours were worked. On one occasion, the Dietary Manager had to cook due to a call-off, and residents reported frequent meal delays of up to an hour, attributed to short staffing.
The facility failed to maintain a clean and sanitary kitchen environment, with appliances covered in food debris and grease, improper food storage, and inadequate sanitation practices. The Dietary Manager cited staffing challenges as a reason for these deficiencies, which could affect the safety and quality of food for the 95 residents.
The facility failed to properly dispose of garbage, as observed with an open dumpster and surrounding debris. Dietary Aides noted the dumpster is often overflowing, especially on weekends. This deficiency could impact all 95 residents.
The facility failed to maintain the walk-in refrigerator at the correct temperature, with issues such as a loose gasket, improper shelf repair, and condensation collection. The Dietary Manager reported these issues, but no repairs were made. The Maintenance Supervisor was unaware of the problems due to a backlog of work orders. The facility's Administrator in Training confirmed the absence of work order copies, except for one. These deficiencies potentially affected all 95 residents.
The facility failed to maintain an effective pest control program, resulting in flies and gnats in the kitchen, dining room, and resident rooms. Flies were observed landing on food and clean items in the kitchen, and residents reported issues with flies in their rooms. An appliance meant to control flies was found unplugged in the dining room.
A resident with a history of inappropriate behavior, including spitting and making unwanted physical contact, continued to abuse other residents despite being on 1:1 supervision and having interventions in place. The facility's incident logs document multiple occurrences of this resident's abusive behavior towards others, highlighting a failure to protect residents from abuse.
The facility did not accommodate a resident's shaving preferences because mirrors were removed from shower rooms during remodeling. A resident reported being unable to shave, and a CNA confirmed that residents had to request staff assistance to shave in their rooms where mirrors were available.
A facility failed to honor a resident's request to empty their urinal at night, resulting in the resident enduring the smell of urine throughout the night. A CNA confirmed that the urinal was often full when they arrived for their shift, despite the facility's policy to treat residents with dignity and maintain a clean environment.
A facility failed to provide a bed hold notification to a resident transferred to the hospital, as required by their policy. The resident was hospitalized and returned with new orders for an antibiotic due to a urinary tract infection. The facility administrator confirmed that no bed hold notification was recorded for this hospital stay.
A facility failed to update a resident's care plan and conduct quarterly elopement risk assessments, despite the resident's high risk for wandering and exit-seeking behavior. The resident, with a history of paranoid schizophrenia and anxiety disorder, attempted to leave the facility multiple times. Staff confirmed the lack of personal safety devices or alarms and the absence of required assessments.
A facility failed to provide appropriate dialysis care for a resident by not ensuring proper communication and collaboration with the dialysis unit. The resident's care plan lacked specific details about dialysis schedules and access site care, and communication forms were inconsistently completed. Additionally, there were no instructions in the resident's room regarding the care of the fistula, potentially compromising the resident's dialysis care.
A resident with moderate cognitive impairment physically assaulted another resident during a meal, leading to a deficiency in preventing resident-to-resident abuse. The incident, witnessed by an RN, involved a misunderstanding over seating and food, resulting in the aggressor striking the other resident. The assaulted resident, with multiple psychiatric diagnoses, expressed confusion and fear during the event.
The facility did not follow its abuse policy by failing to investigate a resident-to-resident altercation involving two residents with behavioral issues. Despite the policy requiring thorough investigations, including staff interviews, the administrator chose not to investigate further after speaking with the residents involved, who reported being fine. This incident was not reported to the State Department of Public Health, highlighting a deficiency in the facility's adherence to its abuse prevention procedures.
The facility failed to report a physical altercation between two residents to the State Agency, as required by its Abuse Prevention and Prohibition Policy. The incident, which occurred in the dining room, involved a verbal altercation escalating into a physical one. Despite the policy mandating reports for all physical altercations, the Administrator did not report the incident, highlighting a lapse in following established procedures.
The facility did not conduct a thorough investigation into a resident-to-resident altercation, as required by its Abuse Prevention and Prohibition Policy. The incident involved two residents in the dining room, where one reportedly initiated a physical altercation. Although the residents were separated and assessed, the facility failed to interview staff or obtain witness statements, leading to a noted deficiency.
A facility failed to document the justification for not readmitting a resident after a hospital stay. The resident, with a history of mental health issues, was sent to the hospital for evaluation. Despite the hospital's notes indicating stability, the facility did not document the reason for refusal to readmit, nor did they communicate with the hospital about the resident's condition. The administration cited the lack of a private room as the reason, but this was not documented, and the facility's physician was not involved in the decision.
A resident was not readmitted to the facility after a psychiatric hospitalization due to the facility's inability to meet the resident's needs for a private room. Despite the hospital's communication of the resident's stability and readiness for discharge, the facility lacked a Transfer/Discharge policy and did not facilitate the resident's return, resulting in an extended hospital stay.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident in which one resident was observed to have nonconsensual physical contact with another resident in a common area. According to the facility's records and staff interviews, one resident approached another and touched her chest without her permission or consent. The incident was witnessed by a staff member, who intervened and reported the event. The resident who was touched confirmed that the contact was unwanted and made her feel uncomfortable. The resident who initiated the contact admitted to the action and stated he did not know it was wrong because the other resident did not tell him to stop. Facility documentation, including the Abuse Prevention and Prohibition Policy, clearly states that residents have the right to be free from all forms of abuse, including sexual abuse, and that such abuse is defined as non-consensual sexual contact of any type. Despite these policies, the incident occurred in a supervised area, and multiple staff members, including the administrator, were made aware of the event through direct observation and resident reports. The records indicate that the facility did not prevent the occurrence of nonconsensual sexual contact between residents.
Failure to Notify Family of Resident's Return from Hospital
Penalty
Summary
The facility failed to notify a resident's family member of the resident's return from the hospital, as required by facility policy. The policy directs staff to inform the resident's family or representative and medical practitioner of significant changes, including transfers, and to document each attempt to contact them. In this case, a resident with a history of mental health issues was transferred to the emergency room after exhibiting increased behaviors and delusions. The resident returned to the facility later that morning, displaying agitation and refusing vital signs. Despite being the resident's guardian, the family member was not informed of the resident's return and only learned of it after contacting the facility the following day. The administrator confirmed that the family member had not been notified of the resident's return.
Failure to Update Care Plan After Repeated Elopement Attempts
Penalty
Summary
The facility failed to update and revise the care plan for a resident who made repeated attempts to elope from the facility on two separate occasions. According to the facility's own care planning policy, staff are required to use assessment data to develop and update a comprehensive plan of care that addresses each resident's needs. Despite documentation in the nursing progress notes that the resident left the building through the front door and, on a later date, exited into the parking lot and down the street while becoming combative, no new interventions were added to the resident's care plan after these incidents. The resident's care plan, last revised prior to the elopement attempts, already identified the individual as an elopement risk and included interventions such as distraction, monitoring for fatigue and weight loss, and redirection. However, after the documented elopement events, the care plan was not reviewed or updated to include additional measures. This was confirmed by the Care Plan Coordinator, who acknowledged that the management team did not revise the plan following the resident's recent attempts to leave the facility unattended.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met according to their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Failure to Follow Discharge/Transfer Policy During Resident Hospitalization
Penalty
Summary
The facility failed to follow its own Discharge/Transfer policy for a resident who was hospitalized. According to the facility's policy, an SBAR (Situation Background Assessment Recommendation) assessment should be completed prior to contacting the provider, and a provider order should be obtained and entered into the electronic health record before transferring a resident to the emergency room or hospital. In this case, the resident, who had diagnoses including Paranoid Schizophrenia, Major Depression Disorder, and Hypertension, complained of multiple episodes of loose stool, nausea, and abdominal pain, and requested to be sent to the hospital. The DON was informed, and the resident was sent to the hospital via ambulance for further evaluation. Upon review, it was found that the required SBAR form was not completed prior to the transfer, and there was no documentation of a provider order authorizing the transfer. Interviews with facility staff confirmed that the SBAR was not completed and that there was uncertainty regarding the policy requirement for obtaining a physician's order before sending a resident to the emergency room. The facility was unable to provide any documentation regarding the transfer, indicating a failure to adhere to established procedures for resident transfers.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of behavioral problems, including aggression and a moderate risk designation, physically struck another cognitively intact resident on the head following a verbal altercation. The incident took place in a common area near the nurse's station, where the aggressor, who has diagnoses including Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Dementia with Moderate Agitation, was involved in an argument over towels. Witnesses, including another resident and an LPN, confirmed that the aggressor became upset and hit the other resident after being confronted about his behavior. The facility's own policies require close supervision and more frequent observation for residents identified as moderate risk, particularly those with a history of aggression and behavioral issues. Documentation shows that the aggressor required attentive monitoring and periodic assessment to determine if the level of supervision was adequate. Despite these requirements, the physical altercation occurred, resulting in the cognitively intact resident being struck and calling for help, with staff responding after the incident had already taken place.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents with known behavioral histories. One resident, who had diagnoses including schizoaffective disorder, alcohol-induced dementia, and severe cognitive impairment, was on one-to-one monitoring due to a history of verbal and physical aggression. Despite this, while in the dining room, this resident was approached by another resident who touched his shoulder and began shouting. The first resident became startled, stood up, and began swinging his arms, striking the other resident in the mouth and causing bleeding. Multiple staff members were present and attempted to intervene, but the incident still resulted in physical harm. The investigation revealed that the resident who initiated the physical contact had a history of behavioral problems, including yelling, cursing, and physical aggression. Staff interviews confirmed that the aggressive resident struck both the other resident and several staff members during the incident. The event was witnessed by several CNAs and a social service assistant, who described the escalation and the immediate efforts to separate the residents and evacuate the dining room. Documentation showed that the resident responsible for the physical aggression was under one-to-one supervision at the time, yet was able to physically harm another resident and staff. The facility's abuse investigation did not include comprehensive witness identification or detailed accounts from all present, limiting the ability to fully reconstruct the incident. The event was reported to the administrator, physician, and local law enforcement, and the aggressive resident was temporarily sent to a hospital for evaluation before returning to the facility.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough abuse investigations for three residents out of thirteen reviewed for abuse. According to the facility's Abuse, Prevention, and Prohibition Policy, the Administrator is responsible for ensuring a comprehensive investigation of all alleged violations, including interviewing all potential witnesses and documenting appropriate actions. However, in the case of a physical altercation between two residents in the dining room, the investigation did not include interviews with all possible witnesses, such as tablemates or other residents present during the incident. The staff and resident interview forms used were generic and did not capture specific details about the event, and there was no documentation identifying who witnessed the altercation. Additionally, in a separate incident involving an allegation of verbal and mental abuse by a consultant towards a resident, the investigation was similarly lacking in detail. The Administrator was unaware of the allegation until informed by the State Agency and initiated an investigation only after being notified. The investigation consisted of generic questions to staff and residents, with no specific questions related to the alleged verbal abuse. The resident involved denied knowing the accused staff member and reported feeling safe, but also mentioned that other staff and residents had made derogatory comments, which was not further explored in the investigation. Interviews with facility staff confirmed that the Administrator did not maintain a list of witnesses for the incidents and did not retain original handwritten statements after typing them up. The Administrator acknowledged that the investigations did not include detailed or specific interviews regarding the incidents and confirmed that the process relied on non-specific forms rather than targeted questioning of those directly involved or present during the alleged events.
Failure to Maintain Continuous 1:1 Supervision for Aggressive Resident
Penalty
Summary
The facility failed to provide continuous one-to-one supervision for a resident with a history of physical aggression and impulsive behaviors, as required by the facility's in-service documentation. The documentation specified that residents on one-to-one supervision should never be out of sight and must always be accompanied by staff. The resident in question had multiple diagnoses, including schizoaffective disorder, alcohol-induced dementia with behavioral disturbances, and severe manic episodes with psychotic symptoms. The resident was placed on one-to-one supervision due to these behaviors and the inability to consent to medication. On the morning of 3/11/25, the resident was observed alone in his room with the door closed, making him not visible from the hallway. The CNA assigned to supervise the resident was found assisting another resident in a different room at the same time, leaving the aggressive resident unattended. Both the DON and the Administrator confirmed that the expectation for one-to-one supervision is that the resident must always be within staff eyesight, and the in-service training reiterated this requirement. There was no formal policy on one-to-one supervision, but staff were in-serviced on the procedure.
Failure to Secure Indwelling Urinary Catheter Tubing
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed without the catheter tubing secured to her leg as required by facility policy. The catheter tubing was seen hanging out of the resident's incontinent brief with a clasp dangling, and not attached to a leg strap. The resident confirmed that the tubing was not strapped to her leg and expressed concern about the risk of it being yanked. A CNA verified that there was no leg strap in place, and the Assistant Director of Nursing acknowledged that a stabilizer should have been used for the catheter tubing. The resident's physician order sheet documented the presence of an indwelling urinary catheter, and facility policy specified that the catheter should be secured with a leg strap to minimize friction and movement at the insertion site.
Breach of Resident Privacy Through Group Text Message
Penalty
Summary
The facility failed to maintain the privacy of residents' health information for six residents, as evidenced by a group text message that included snapshots of dietary information cards displaying residents' full names, room numbers, and diet information. This breach of confidentiality involved a group text message shared among 16 people, all CNAs, some of whom no longer work at the facility. The facility's policy, as outlined in the Employee Handbook, emphasizes the importance of protecting Protected Health Information (PHI) in accordance with HIPAA regulations, yet this incident demonstrates a clear violation of these guidelines. The incident was brought to light through interviews and record reviews, revealing that the Administrator was aware of the group text message but could not initially find proof of its existence. The CNA involved, V22, confirmed being part of the group text but was unable to identify who initially shared the dietary cards. Despite the Administrator's in-service training on HIPAA conducted prior to the incident, the breach occurred, and the Director of Nursing confirmed that sharing such information in a group chat constitutes a HIPAA violation. Residents expressed their concerns about privacy, emphasizing the importance of keeping their personal and health information confidential.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident physical abuse, as evidenced by two separate incidents involving unwanted physical contact. In the first incident, a resident with a BIMS score of 14, indicating cognitive intactness, was pushed by another resident, resulting in a fall against a wall. The incident occurred after the resident who was pushed asked the other resident to stay out of her room. The facility's investigation revealed that the push was deliberate, although the instigating factors were unclear to the resident who was pushed. In the second incident, another resident with a BIMS score of 15, also indicating cognitive intactness, was pushed by a fellow resident in the dining room. This occurred after a disagreement over picking up meal tickets for dietary staff. The resident who was pushed did not fall but reported being pushed hard. Both incidents were reported to the state agency, and immediate actions were taken to separate the involved residents and notify relevant parties.
Facility Fails to Maintain Homelike Environment Due to Maintenance Issues
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by various maintenance issues observed in multiple resident rooms. These issues included chipped paint, holes in walls, missing trim, loose cable cords, and unpainted walls. The maintenance supervisor, who has been in the position since August 2024, was unaware of several of these issues until they were pointed out during the survey. The facility's maintenance work orders were not adequately documented or addressed, with no dates for repair entered for several reported issues. In one instance, a maintenance work order dated August 25, 2024, reported holes in the wall of a shared room, but there was no documentation confirming the repair. Residents expressed dissatisfaction with the condition of their rooms, noting that the appearance of the walls bothered them and made them feel less comfortable. The maintenance supervisor confirmed the presence of these issues during the survey but had not noticed them prior to the inspection. The facility's failure to address these maintenance issues in a timely manner resulted in an environment that did not meet the residents' right to a safe, clean, and comfortable living space. The lack of a documented maintenance policy and the absence of a systematic approach to addressing work orders contributed to the ongoing deficiencies in the facility's environment.
Failure to Timely Process Medication Orders
Penalty
Summary
The facility failed to process medication orders in a timely manner, resulting in medications not being administered as per physician orders for six residents. The Medication Administration Policy requires that all medication orders be prescribed by a licensed healthcare professional and documented accurately in the resident's medical records. However, the facility did not adhere to this policy, as evidenced by the Medication Administration Records (MARs) of the affected residents. For instance, a resident with paranoid schizophrenia did not receive their prescribed Aripiprazole on two consecutive days, and another resident with major depressive disorder missed doses of Nortriptyline. Similar issues were noted for residents with bipolar disorder, depression, anxiety disorder, and generalized anxiety disorder, where medications such as Quetiapine, Escitalopram, Trazadone, and Lorazepam were not administered as ordered. The deficiency was primarily due to the process involving the Psychiatric Nurse Practitioner (V6) and the Licensed Practical Nurse (V7). V6 entered medication orders into the Electronic Medical Record (EMR), but these orders remained in a pending status until V7 confirmed them. V7 was responsible for verifying and completing the pending orders, but due to an appointment, V7 did not confirm the orders in a timely manner, leading to a delay in medication administration. The Registered Nurse (V9) and another Registered Nurse (V5) confirmed that the nurses relied on V7 to activate the orders, and without V7's confirmation, the medications were not administered. This lapse in the medication administration process resulted in the residents not receiving their prescribed medications on the specified dates.
Privacy and Dignity Deficiencies for Two Residents
Penalty
Summary
The facility failed to maintain the privacy and dignity of two residents, R59 and R52, as observed during a survey. R59's room door would not latch shut, preventing her from having a private space to dress and reducing noise from the hallway. This issue was known to the facility, as a maintenance work order had been pending since June 29, 2024, but had not been resolved due to the unavailability of a replacement part. The Maintenance Supervisor confirmed the door's malfunction and acknowledged the delay in addressing the issue. Additionally, R52, who has an indwelling urinary catheter, was observed in the dining room with her catheter bag exposed, contrary to her care plan which required the bag to be covered for dignity. Initially, the bag was not covered, and it was only after staff intervention that a blue absorbent pad was used to wrap the bag. The Director of Nursing confirmed that the facility lacked a policy regarding the covering of catheter bags, indicating a gap in the facility's procedures to ensure resident privacy and dignity.
Inaccessible Activity Calendars for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents, R46 and R60, by not ensuring that the activity calendar was accessible and legible for them. R60, who is blind in her right eye, had her activity calendar taped on her bathroom door approximately five feet high, making it difficult for her to see. R60 expressed that she could not see the calendar and required larger print to read it. As a result, R60 missed activities, including nail care, which she found important. R60's Minimum Data Set (MDS) assessment indicated that participating in her favorite activities was very important to her. Similarly, R46's activity calendar was also placed too high on the bathroom door, making it inaccessible for her to see. R46 confirmed that the calendar's placement was too high for her to view. The Director of Nursing (DON) acknowledged that both R46 and R60's calendars were posted too high and printed in a faint and small font size, confirming the residents' inability to see the activities scheduled. Both residents' MDS assessments highlighted the importance of engaging in their favorite activities, which the facility failed to accommodate.
Care Plan Deficiency for Hepatitis C and Blindness
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with Hepatitis C and blindness in the right eye. During an observation, the resident was seen sitting in a wheelchair with a cloudy and distorted right eye, and the resident confirmed blindness in that eye. The resident's face sheet documented diagnoses of unspecified viral Hepatitis C without hepatic coma and blindness in the right eye. However, the current care plan did not address these conditions. The care plan coordinator confirmed the omission, acknowledging that both conditions were significant enough to warrant inclusion in the care plan.
Failure to Implement Nonpharmacological Interventions for Resident's Behavioral Needs
Penalty
Summary
The facility failed to implement nonpharmacological interventions for a resident with mood behavior monitoring needs. The facility's policy requires staff to evaluate residents' mood and behavior patterns and incorporate findings into the care plan, utilizing nonpharmacological approaches to manage behavioral symptoms. However, the medical record of a resident diagnosed with depression and anxiety showed no nonpharmacological interventions for behavior monitoring, despite documentation of verbal and physical behaviors. The Director of Nursing confirmed the absence of such interventions, stating that the resident was only on antidepressants.
Lack of Signed Hospice Contract for Resident
Penalty
Summary
The facility failed to have a signed hospice contract for a resident who was reviewed for hospice services. The resident's medical record included an order dated December 5, 2024, indicating approval for hospice evaluation and treatment. The nurses' notes from the same date documented communication with the resident's Power of Attorney, who agreed to hospice services, and the Medical Doctor was notified. The local hospice was informed, and documentation was faxed as requested. By December 9, 2024, the facility was notified that the resident had been approved for hospice, and a hospice nurse was scheduled to complete the admission. The resident's care plan, initiated on December 11, 2024, confirmed the receipt of hospice services due to a terminal diagnosis related to dementia. Despite these actions, during the survey conducted from January 7 to January 10, 2025, the facility was unable to produce a signed hospice contract, as verified by the Administrator on January 10, 2025.
Survey Book Not Up-to-Date
Penalty
Summary
The facility failed to maintain an up-to-date survey book, which is required to be accessible to residents and their advocates. On January 10, 2025, it was observed that the survey book located in the front foyer area did not contain the most recent survey results. The last survey included in the book was dated April 10, 2024. Additionally, the facility had several complaints filed with the State Agency on October 5, November 8, November 22, and December 18, 2024, which were investigated but not included in the survey book. This oversight was confirmed by the facility's administrator, who acknowledged that the survey book was not current, potentially affecting all 88 residents residing in the facility.
Failure to Maintain Three Years of Resident Grievance Records
Penalty
Summary
The facility failed to maintain the required minimum of three years of resident grievance records, which has the potential to affect all 88 residents residing in the facility. The facility's Resident Grievance Process Policy, reviewed in August 2023, mandates that copies of all grievances be maintained according to the community record retention policy. However, upon review, it was found that the facility's Grievance Binder only contained records for the years 2023 and 2024, lacking documentation for the year 2022, which is necessary to meet the three-year requirement. Interviews with facility staff confirmed the deficiency. The Director of Nursing (DON) acknowledged that the 2022 grievance reports were not available and that the facility only had records for 2023, 2024, and any for 2025. The Administrator also confirmed the absence of grievance records prior to 2023, stating that they could not be located and were unavailable for review. This oversight in maintaining grievance records as per policy could potentially impact all residents in the facility.
Failure to Maintain Resident Account Bookkeeping
Penalty
Summary
The facility failed to maintain a proper bookkeeping system for managing individual resident accounts, affecting all 93 residents. The deficiency was identified when the Administrator, V1, could not provide current balances for any resident accounts due to discrepancies found in the account balances not being carried over. The last available balance report was from September 30, 2023. The facility had been using an electronic account ledger system that was hacked, necessitating a switch to manual ledgers, which was not completed. V5, the Regional Revenue Cycle Manager, was in the process of creating manual account ledgers from the last balance report using various financial documents, estimating a four-week completion time. V4, responsible for Payroll and Human Resources, admitted to difficulties in maintaining the manual ledgers, stating that the process was too much for one person to handle. The manual process had been ongoing for approximately a year, and V4 was unable to keep up with the required documentation. The Administrator, V1, acknowledged that no adequate system had been in place since his employment began in May 2024, and V4 had not been submitting the necessary documents to the corporate office monthly since September 30, 2023. The facility's Resident Trust Fund Policy, last revised in 2012, required a full and complete separate accounting ledger for each resident, with monthly reconciliations and submissions to the corporate office, which were not being followed.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent the physical abuse of a resident, identified as R3, by another resident, R7. According to the facility's Abuse, Prevention and Prohibition Policy, each resident has the right to be free from abuse, including physical abuse. The incident occurred when R3 observed R7 tampering with the diet cards of residents, which could potentially lead to incorrect meals being served. R3 asked R7 to stop, and as R3 bent down to pick up some cards that had fallen on the floor, R7 pulled R3's hair and pushed her head down. The facility's investigation into the incident confirmed that R7's actions constituted physical abuse. Despite attempts to interview both residents about the incident, neither R3 nor R7 was willing to discuss it further. The facility administrator acknowledged the incident as founded physical abuse, although the motive behind R7's actions could not be determined due to R7's refusal to communicate about the event.
Inadequate Management of Involuntary Discharge for Resident with Severe Mental Health Issues
Penalty
Summary
The facility failed to appropriately manage the involuntary discharge of a resident, identified as R1, who had a history of severe mental health issues, including Bipolar disorder, Generalized Anxiety, and Conversion Disorder with Seizures. R1 required continuous supervision and had a documented history of aggressive behaviors, including verbal and physical aggression towards staff and peers, as well as attempts to elope from the facility. Despite these challenges, the facility did not ensure that a signed physician discharge order was in place when serving a notice of involuntary discharge. The report details several incidents involving R1 that led to her being sent to a local hospital for psychiatric evaluation. These incidents included physical altercations with other residents, attempts to leave the facility, and aggressive behavior towards staff. On one occasion, R1 was involved in a physical altercation with another resident, and on another, she attempted to break windows and spat on staff. Despite these behaviors, the facility's documentation did not include a signed physician order for R1's discharge, which is a requirement for involuntary discharge. Interviews with facility staff, including the Director of Nursing and a Certified Nursing Assistant, revealed that R1's aggressive behaviors were consistent and not new. However, on the day of the involuntary discharge, R1's behavior was described as being at a new level of severity. The facility's failure to obtain a signed physician order for the discharge, despite the documented need for such an order, constitutes a deficiency in the facility's handling of the situation.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for a resident who was reviewed for involuntary discharge. The resident had a history of Bipolar Disorder, Generalized Anxiety Disorder, and Conversion Disorder with Attacks or Seizures, and required continuous assistance with activities of daily living, safety, and mental health management. The resident's care plan included interventions for managing agitation and aggression, as well as addressing risks for elopement and ineffective coping due to PTSD. Despite these documented needs, the facility did not offer the resident any one-on-one social service visits, group therapies, or behavioral management interventions during their stay. The facility's assessment indicated that it was equipped to manage mental health and behavioral needs, including providing psycho/social/spiritual support and opportunities for social activities. However, the social services notes for the resident only documented multiple referrals for placement in other facilities, with no evidence of the required psychosocial therapies being provided. Interviews with facility staff revealed that the social services department was newly established and lacked in-house psychiatric services or group therapies at the time of the resident's stay. The Director of Nursing confirmed that psychiatric visits were conducted through telehealth, and the facility administrator acknowledged the absence of psychosocial therapies during the resident's stay. The social services department was in transition, with a new team and a recently appointed Social Services Director, which contributed to the lack of services provided to the resident. This deficiency highlights the facility's failure to meet the resident's documented needs for social and behavioral support, as outlined in their care plan and preadmission screening.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager in the kitchen, which has the potential to affect all 95 residents living in the facility. The job description for the Dietary Supervisor outlines responsibilities such as participating in the nutrition assessment process, providing progress notes in residents' medical records, and participating in care conferences. However, the current Dietary Manager, identified as V15, is not certified and has not been enrolled in a certification program despite being informed by management that certification was necessary. During an interview, V15 admitted to not performing clinical nutrition tasks for residents, such as reviewing weight records or completing the Minimum Data Set (MDS) section. V15 stated that they are often occupied with filling in for absent staff in the dietary department, indicating a lack of focus on the essential duties outlined in the job description. This deficiency was documented in the facility's Long-Term Care Facility Application for Medicare and Medicaid, which recorded 95 residents residing in the facility at the time of the survey.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient staff to effectively carry out the functions of the food and nutrition service, potentially affecting all 95 residents. The Facility Assessment indicated that staffing should ensure sufficient personnel to meet residents' needs, with budgeted hours ranging from 900 to 945 hours per two-week payroll period. However, the Time Detail Report for the period from 7/07/24 to 7/20/24 showed only 301.25 hours worked in the Dietary Department. On 7/21/24, only three dietary employees were present, with the Dietary Manager having to cook due to the absence of the scheduled morning cook. The Dietary Manager noted frequent call-offs and staffing shortages. During a Resident Council Meeting, several residents reported that meals were often served 30 to 60 minutes late, with staff citing short staffing in the kitchen as the reason.
Facility Fails to Maintain Clean and Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a surveyor's visit. The kitchen was found to be unkempt and dirty, with various appliances such as the convection oven, range, grill, and dishwasher area covered in dried food splashes, grease, and debris. The walls and drawers in the kitchen also had visible food debris and dust. Additionally, storage containers were improperly placed on the floor, and food items were not labeled or dated as required. Eggs were stored incorrectly, posing a risk of contamination to other food items. The facility also failed to maintain proper sanitation practices. The chlorine level in the low-temperature dish machine was not consistently tested, and there was no log of the dishwasher chlorine tests. The sanitation bucket, which contained quaternary ammonia, was not tested with the appropriate test strips, and staff were unaware of the correct procedures for testing and logging the sanitation solution. This lack of proper sanitation practices could potentially affect the safety and quality of food served to the 95 residents in the facility. The Dietary Manager, V15, acknowledged the issues and attributed them to staffing challenges, stating that staff frequently called off, leaving her to handle cooking and food preparation duties. This situation made it difficult to maintain cleanliness and sanitation standards, and the manager admitted that it was a challenge to get meals out on time. The facility's failure to adhere to professional standards for food storage, preparation, and sanitation was evident, as documented in the surveyor's findings.
Improper Garbage Disposal and Maintenance
Penalty
Summary
The facility failed to maintain proper disposal of garbage and refuse, as evidenced by the observation of an open large outside garbage dumpster and debris surrounding the area. This deficiency was noted during an observation on 7/21/24 at 11:30 AM when two Dietary Aides, V20 and V21, were seen taking trash containers to the dumpster. The dumpster lid was open, and several items had fallen onto the ground, with weeds surrounding the dumpster. V20, a Dietary Aide, mentioned that the dumpster is often full to overflowing, particularly on weekends. The facility's document on Garbage Disposal, which lacks a date, specifies that storage areas should be kept clean to deter pests and that outdoor trash receptacles should be covered with the surrounding area free of litter. This deficiency has the potential to affect all 95 residents residing in the facility.
Refrigerator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the walk-in refrigerator at the correct temperature, with the thermometer inside the unit registering 50 to 52 degrees Fahrenheit, above the required 41 degrees Fahrenheit or below. The door to the refrigerator had a gap due to a loose gasket, which the Dietary Manager unsuccessfully attempted to reattach. Additionally, a yellow bucket, typically used for scrubbing floors, was found half full of black dirty water, collecting condensation from a hose coming down from the fan box area. The top shelf in the refrigerator was improperly repaired with a zip-tie, which had broken, causing the shelf to be at a 45-degree angle. The Dietary Manager reported that work orders had been submitted for these issues since December, but no repairs had been made. The Maintenance Supervisor was unaware of the problems with the walk-in refrigerator and had not reviewed the work orders due to being the only maintenance person for the past four months. The facility's Administrator in Training confirmed that the Dietary Manager had resigned and that the work orders she claimed to have copied could not be found, except for one dated 7/12/24. The facility's documentation indicated that 95 residents resided within the facility, all potentially affected by these deficiencies.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and gnats in the kitchen, dining room, and resident rooms. During a kitchen tour, flies were observed landing on food items being prepared, on food items in the steam table, and on clean dishes, glasses, plates, and silverware. Flies were also seen landing on the Dietary Manager and Dietary Aides, indicating a persistent issue. The Dietary Manager acknowledged the constant presence of flies, stating that they are also present in the dining room. During the Resident Council Meeting, several residents reported the presence of flies in the dining room and their bedrooms, with one resident mentioning that flies and gnats become particularly problematic in their room. An appliance intended to eliminate flies was found in the dining room but was not plugged in or functioning. The facility's documentation confirmed that 95 residents currently reside within the facility, all potentially affected by this issue.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, identified as R32, who has a history of inappropriate behavior, including spitting on others. R32 was admitted with diagnoses of Bipolar Disorder and Generalized Anxiety Disorder. Despite being on 1:1 supervision and having interventions in place, such as encouraging R32 to wear a surgical mask and providing a cup for spitting, R32 continued to engage in abusive behavior towards other residents. The incidents included spitting on multiple residents during meals and in common areas, making unwanted physical contact, and throwing ice on a resident. The facility's incident logs and reports document multiple occurrences of R32's abusive behavior towards other residents over a period of time. These incidents involved R32 spitting on residents during meals, in the dining room, and in the smoking area, as well as pushing a resident to sit in a chair and throwing ice on another resident. The facility's administrator acknowledged the difficulty in meeting R32's needs and the ongoing attempts to implement new interventions to prevent further abuse. However, the repeated incidents indicate a failure to effectively protect residents from abuse by R32.
Failure to Accommodate Shaving Preferences Due to Lack of Mirrors
Penalty
Summary
The facility failed to accommodate the shaving preferences of a resident due to the absence of mirrors in the shower rooms. During an observation, it was noted that all four resident shower rooms lacked mirrors, which are essential for residents to shave. A resident expressed that he was unable to shave because of this deficiency. A Certified Nurse Aide confirmed that the mirrors were removed during a recent remodeling of the facility. As a result, residents who wished to shave had to request assistance from staff, who would then provide a razor and supervise the shaving in the resident's room where mirrors were available. However, the usual practice was for residents to shave in the shower rooms, which was no longer feasible due to the lack of mirrors.
Failure to Honor Resident's Request for Urinal Disposal
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not complying with a request to discard odorous urine at the bedside. The resident, identified as R60, reported that staff did not empty their urinal at night, resulting in the resident having to endure the smell of urine throughout the night. This was corroborated by a Certified Nursing Assistant (CNA), who noted that the urinal was often full when they arrived for their shift, and acknowledged that the resident might refuse to be changed at night, but emphasized that the urinal should still be emptied. The facility's Residents' Rights policy, revised in November 2018, mandates that residents be treated with dignity and respect, and that the facility should promote a safe, clean, and homelike environment, which was not upheld in this instance.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a bed hold notification to a resident who was transferred to the hospital, which is a requirement according to their Bed Hold Policy and Agreement. This policy, dated February 2024, mandates that the facility must notify the resident or their representative about the bed hold policy whenever a resident is transferred to a hospital or takes therapeutic leave. In this case, a resident was sent to the hospital on March 13, 2024, and returned to the facility on March 15, 2024, with new orders for an antibiotic due to a urinary tract infection. However, the facility administrator admitted that there was no record of a bed hold notification being given to the resident or their representative for this hospital stay.
Failure to Update Elopement Risk Care Plan and Conduct Quarterly Assessments
Penalty
Summary
The facility failed to adhere to its elopement policy by not updating a resident's care plan to reflect their high risk for elopement and by not conducting the required quarterly assessments. The resident, who has diagnoses of paranoid schizophrenia, anxiety disorder, and other psychological conditions, was identified as having a high risk to wander or exit seek based on an evaluation conducted in November 2023. Despite this, the resident's care plan did not include necessary interventions such as ensuring the resident wore a personal safety device or that facility doors were alarmed, as stipulated by the facility's policy. The resident's medical records revealed multiple instances where the resident attempted to exit the facility unsupervised, indicating a pattern of elopement behavior. Progress notes documented several attempts by the resident to leave the facility through various doors, with the resident expressing intentions to leave for specific reasons, such as waiting for a car or going on a dinner date. Interviews with facility staff confirmed that the required elopement risk assessments were not conducted quarterly, and the facility did not utilize personal safety devices or alarms to prevent such incidents.
Inadequate Dialysis Care and Communication for Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident requiring renal hemodialysis, as evidenced by a lack of documented collaboration and communication with the dialysis unit. The Dialysis Services Coordination Agreement and facility policies require documented evidence of collaboration and communication between the long-term care facility and the dialysis unit, including the use of a dialysis communication form. However, the resident's progress notes lacked evidence of such collaboration, and the dialysis communication forms were inconsistently completed, with only twenty-six out of sixty-one forms filled out between March and July 2024. Additionally, some forms lacked signatures or post-dialysis assessments, making it unclear if the resident received dialysis on those occasions. The resident's care plan and physician's orders were also found to be inadequate. The care plan did not specify the days or times of scheduled dialysis treatments, nor did it include instructions for blood pressure monitoring or details about the dialysis access site. The physician's orders did not specify the type or location of the dialysis access site, nor which arm to avoid for blood pressure measurements. Furthermore, there were no signs or instructions in the resident's room regarding the care of the fistula, such as avoiding blood pressure measurements or blood draws from the left arm. This lack of detailed documentation and communication could potentially compromise the resident's dialysis care.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents. An incident occurred where one resident, diagnosed with mild neurocognitive disorder and a history of aggressive behavior, physically assaulted another resident during a meal. The aggressor, who has a BIMS score indicating moderate cognitive impairment, struck the other resident in the abdomen and back after a misunderstanding over seating and food. The assaulted resident, who has a BIMS score indicating cognitive intactness, was shocked by the incident and was still processing the event. The incident was witnessed by a registered nurse who reported that the aggressor attempted to sit in the other resident's chair, leading to a verbal exchange and subsequent physical altercation. The assaulted resident, who has multiple psychiatric diagnoses including PTSD and bipolar disorder, expressed confusion and fear during the incident. The facility's failure to prevent this altercation highlights a deficiency in protecting residents from abuse, as outlined in their Abuse Prevention and Prohibition Policy.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Prohibition Policy by not conducting a thorough investigation into an incident of resident-to-resident abuse involving two residents, R6 and R9. According to the policy, the facility is required to ensure a comprehensive investigation of any alleged violations of individual rights, which includes interviewing all employees working on the specific hall or wing where the incident occurred. However, the facility's administrator decided not to pursue further investigation after speaking with the involved residents, R6 and R9, who reported being fine post-incident. This decision was made despite the policy's requirement for interviews and witness statements from staff or residents who might have knowledge of the incident. The incident in question involved R6 and R9, who were involved in a physical altercation in the dining room. R6, who has a history of aggressive behavior and a BIMS score indicating moderate cognitive impairment, reported that R9 initiated the altercation by throwing a tea cup at him. R9, who has a BIMS score indicating cognitive intactness, is noted to have a history of inappropriate behaviors. The facility's failure to report the incident to the State Department of Public Health and to conduct a thorough investigation as per their policy constitutes a deficiency in following established procedures to prevent abuse and ensure resident safety.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for two residents involved in a physical altercation. According to the facility's Abuse Prevention and Prohibition Policy, the Administrator is responsible for ensuring a thorough investigation of alleged violations and reporting them to the mandated state agency. However, the altercation between the two residents, which occurred in the dining room, was not reported to the state authorities as required. The incident involved a verbal altercation that escalated into a physical one, with the residents being separated immediately and assessed by the staff. The Administrator acknowledged that reports should be sent to the State Department whenever there is a physical altercation, regardless of whether an injury occurs. Despite this policy, the altercation between the two residents was not reported, indicating a failure to adhere to the facility's established procedures for handling and reporting such incidents. This oversight was identified during interviews and record reviews conducted by the surveyors.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of resident-to-resident abuse involving two residents. According to the facility's Abuse Prevention and Prohibition Policy, a comprehensive investigation should include interviews with witnesses, staff, residents, or visitors who might have knowledge of the incident. However, in the case of the altercation between the two residents, the facility did not conduct interviews with the staff or obtain witness statements. The incident occurred in the dining room, where one resident reportedly initiated a physical altercation with another. Although the residents were separated and assessed immediately, the lack of a thorough investigation was noted as a deficiency.
Failure to Document Justification for Resident's Non-Readmission
Penalty
Summary
The facility failed to provide adequate documentation and justification for the refusal to readmit a resident, identified as R2, after a hospital stay. The facility's policy requires that involuntary discharges be documented by a physician, detailing why the resident's needs cannot be met at the facility. However, in this case, there was no documentation from a physician regarding the basis for R2's involuntary discharge or the specific needs that could not be met. R2 had a history of mental health issues, including Bipolar Disorder, Auditory Hallucinations, and Schizoaffective Disorder, and was sent to the hospital for a psychiatric evaluation due to increased confusion, hallucinations, and aggressive behavior. Despite the hospital's progress notes indicating R2 was coherent and without psychotic thought content, the facility did not document the reason for not readmitting R2, nor did they document any communication with the hospital regarding R2's condition upon the hospital's request for return. The facility's administration and social service director admitted to not documenting the decision-making process or the resident's status at the time of the hospital's request for return. The facility's administrator in training stated that R2 was not accepted back due to the lack of a private room, which was deemed necessary for R2's needs due to her behaviors. However, this decision was not documented, and the facility's physician was not involved in the decision-making process, highlighting a lack of communication and documentation regarding the resident's discharge and readmission process.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident, identified as R2, to return to the nursing home after a psychiatric hospitalization, which exceeded the bed-hold policy. R2, who was covered by Medicaid, was hospitalized for psychiatric evaluation and treatment due to delusions, suicidal and homicidal ideations, and self-harm. Despite the hospital's attempts to communicate R2's readiness for discharge and the facility's initial indication that R2 could return once stable, the facility did not accept R2 back, citing an inability to meet R2's needs for a private room due to behavioral issues. The facility's lack of a Transfer/Discharge policy contributed to the deficiency, as there was no documented procedure to address the return of residents after hospitalization. The facility's Administrator in Training (AIT) and Social Service Director (SSD) both indicated that R2 was not accepted back due to the need for a private room, which the facility could not provide. The hospital's Licensed Clinical Social Worker (LCSW) reported multiple attempts to contact the facility for updates and to arrange R2's return, but these efforts were met with no response. R2 remained in the hospital for over 30 days, awaiting nursing home placement, as the facility did not facilitate R2's return. The hospital's medical staff confirmed R2's stability and readiness for nursing home placement, but the facility did not have a policy to guide the process of readmitting residents after hospitalization. This lack of policy and communication resulted in R2's prolonged hospital stay, as the facility did not take the necessary steps to readmit R2 or provide a clear plan for discharge and transfer.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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