Evercare Of Collinsville
Inspection history, citations, penalties and survey trends for this long-term care facility in Collinsville, Illinois.
- Location
- 614 North Summit, Collinsville, Illinois 62234
- CMS Provider Number
- 145438
- Inspections on file
- 34
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 9 (2 serious)
Citation history
Health deficiencies cited at Evercare Of Collinsville during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of frequent falls was not properly monitored or provided with effective fall prevention interventions, resulting in multiple injuries and repeated hospital visits. Staff failed to follow care plan interventions, did not perform regular checks, and left the resident soiled in bed for hours with the call light out of reach. These actions and inactions led to a finding of neglect and Immediate Jeopardy.
A resident with severe cognitive impairment and a history of frequent falls experienced repeated injuries due to the facility's failure to implement and follow individualized fall prevention interventions. Staff did not consistently keep the call light within reach, provide adequate supervision, or update care plans after each fall, resulting in multiple injuries and emergency room visits. Observations also revealed lapses in incontinence care and improper transfer techniques, despite clear facility policies and expectations.
Two residents dependent on staff for ADLs were left in urine and feces for extended periods without timely or complete incontinent care. Staff failed to follow proper hygiene and infection control protocols, including hand hygiene and thorough peri-care, and did not check residents for incontinence as required by facility policy.
Staff failed to perform required hand hygiene before, during, and after providing care to multiple residents, including during incontinent care and G-tube procedures. CNAs and an LPN were observed not sanitizing hands before donning gloves, between glove changes, or after completing care, despite facility policy and staff knowledge of proper infection control practices.
A resident's room window was found to have a hole, allowing flies and outside air to enter due to an inadequately secured plexiglass cover. The issue was not reported through the facility's maintenance work order system, resulting in the deficiency going unaddressed until discovered during a survey. Staff interviews confirmed that the established process for reporting and repairing such issues was not followed.
A facility failed to conduct required background checks on employees with direct resident contact, resulting in a resident with mental health diagnoses experiencing verbal abuse from a staff member. The incident caused the resident significant emotional distress and reluctance to leave their room. The facility could not verify that background checks had been completed for the staff member involved, as required by policy.
The facility did not complete required background checks for several staff members who had direct contact with residents, resulting in a situation where a resident with mental health diagnoses experienced verbal abuse from a staff member. The resident reported significant emotional distress, and the facility's failure to follow its own screening policies affected all residents.
A resident experienced multiple falls, including one where he was unable to reach his call light and had to call 911 for help due to insufficient staff presence. First responders had difficulty locating staff, eventually finding a nurse and another staff member outside, both unaware of the resident's situation. Staffing records showed fewer CNAs than scheduled, and the resident was found on the floor with dried blood, having tried to get attention with a broken coat hanger.
A resident with severe cognitive impairment and a history of repeated falls experienced multiple falls over a two-month period, but the facility did not notify the resident's family of these incidents or any resulting injuries, contrary to facility policy. The family only became aware of an injury after observing it during a visit and asking staff. Staff interviews confirmed that family notification was expected but not consistently performed.
A resident's legal representative, holding power of attorney, submitted a HIPAA-compliant request for medical records after the resident's discharge. The request was received by social services and reportedly forwarded to administration, but the administrator and clinical leadership stated they never saw the form. As a result, the records were not provided within the required timeframe.
The facility did not consistently update individualized care plans or complete fall risk evaluations after multiple residents experienced falls, including unwitnessed incidents and falls occurring outside the facility. Despite documented physical and cognitive impairments, care plans and interventions were not revised as required by facility policy, and staff interviews confirmed these lapses.
Mechanical lifts used for resident transfers were not maintained in safe working order, with staff observed struggling to control malfunctioning equipment and residents expressing fear and discomfort during use. Staff reported ongoing issues with the lifts, including malfunctioning legs and dead batteries, but the facility's reporting and maintenance processes failed to address these problems, resulting in continued use of unsafe equipment.
Surveyors found multiple bathrooms and shower areas with visible mold, strong bleach odors, and unclean conditions, including missing tiles and crumbling walls. Residents and staff confirmed ongoing mold issues, with some residents limiting showers due to unsanitary conditions and staff reporting illness related to mold exposure. Housekeeping efforts to address mold were described as insufficient, and the facility's policy for immediate cleaning was not effectively implemented.
A resident with epilepsy did not receive prescribed anti-seizure medications for several days after staff, acting on concerns about possible double dosing by a family member, obtained an order from a covering nurse practitioner to hold the medications. The situation was not promptly assessed or clarified, and there was no direct communication with the resident's specialists. During this period, the resident experienced a seizure and required emergency treatment. The facility lacked a policy on continuity of care to guide staff in such circumstances.
A resident with epilepsy did not receive multiple doses of prescribed anti-convulsant medications due to delays in refilling and lack of availability, resulting in a seizure episode that required emergency room evaluation. Facility records and staff interviews confirmed missed doses, lack of timely reordering, and absence of the medication in the emergency kit, with no documentation explaining the delay.
The facility failed to properly clean dishes and store food, risking foodborne illness for all 55 residents. A cook skipped the rinsing step in the dishwashing process due to a missing stopper, and food items in the refrigerator and freezer were not labeled or dated as per policy.
A facility failed to thoroughly investigate an abuse allegation involving a resident with multiple health conditions. The resident claimed to have been hit by a night CNA, but initial assessments showed no injuries, and camera reviews found no interaction. The administrator admitted to not asking the correct questions during interviews with other residents, leading to an incomplete investigation and a deficiency in handling the abuse allegation.
A resident's care plan failed to address pain management despite documented pain and prescribed medications. The resident reported chronic pain, and the MDS/Care Plan Coordinator acknowledged the oversight, citing frequent hospital discharges as a possible reason. The facility's policy requires comprehensive care planning, including pain management.
The facility failed to meet the required minimum floor space per resident bed, with several two-bed rooms providing less than the mandated 80 square feet per resident. Observations confirmed that 26 residents were affected by this deficiency.
The facility failed to maintain an effective pest control program, resulting in a roach infestation affecting all 56 residents. Observations and interviews revealed roaches in various areas, and staff reported that the maintenance man responsible for pest control was terminated for not performing his duties. The pest control company recommended monthly services, but financial issues led to a lapse in treatment, exacerbating the infestation.
Failure to Prevent Neglect and Address Fall Risks
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including schizophrenia, malnutrition, and a history of frequent falls, was not adequately monitored or provided with appropriate interventions to prevent neglect and injury. Despite being identified as a high fall risk and having a care plan that documented numerous falls, staff repeatedly failed to implement or update fall prevention interventions after each incident. The resident experienced multiple falls, some resulting in injuries that required emergency room visits, yet new or effective interventions were often not put in place, and fall risk assessments were missing after several incidents. In addition to the failure to address fall risks, staff did not consistently follow existing care plan interventions such as frequent toileting, ensuring the call light was within reach, and performing regular checks. The resident was observed on several occasions lying in bed for extended periods, saturated in urine and feces, with the call light out of reach and the door closed, making the resident not visible to staff. Staff members were seen opening the door, looking in, and leaving without providing care or cleaning the resident, even after being aware of the resident's condition. The resident remained soiled for at least five hours, and staff failed to respond to his needs despite clear evidence of incontinence and discomfort. Interviews with staff and medical professionals confirmed that the standard of care was not met, as the resident was left unattended and in an unhygienic state, and interventions to prevent falls and address incontinence were not followed. The facility's own policies defined such actions as neglect, including inadequate provision of care, poor hygiene, and leaving someone unattended who needs supervision. The repeated lack of appropriate response and disregard for the resident's care, comfort, and safety led to the identification of neglect and the declaration of Immediate Jeopardy.
Removal Plan
- R2 was provided with 1:1 sitter.
- DON/ADON completed skin assessment on R2 with no negative outcomes noted.
- Administrator, DON & ADON were in-serviced by the RNC on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Administrator in-serviced all department heads on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Department managers in-serviced department staff members on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Staff will not work until in-serviced on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- DON/ADON/Department Manager will in-service any future agency employees on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- The DON/ADON/Licensed staff completed skin assessment on residents requiring incontinent care.
- A quality assurance tool was implemented: DON/ADON/CNA Supervisor will conduct audits on residents requiring incontinent care and completed in timely manner.
- A quality assurance tool was implemented for SSD (Social Service Director) or designee to conduct resident interviews to ensure there are no concerns related to Abuse/Neglect.
- The DON/ADON will complete audit review during daily morning clinical meeting to ensure compliance.
- Audit tool will also include review of new/re-admit fall risk assessments for resident high risk to ensure prevention measure are in place.
- Root cause analysis completed for neglect related to coordination of care provided to residents.
Failure to Implement and Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to provide effective fall prevention and adequate supervision for a resident with a documented history of frequent falls and severe cognitive impairment. This resident experienced 50 falls over an eight-month period, many resulting in injuries such as hematomas, lacerations, and head injuries, some of which required emergency room visits. Despite being identified as a high fall risk and having multiple interventions listed in the care plan, staff did not consistently implement or update these interventions after each fall, and several falls were not addressed in the care plan at all. Additionally, fall risk assessments were not completed after every incident as required by facility policy. Observations and interviews revealed that staff often failed to keep the resident's call light within reach, did not maintain the resident in visible areas for supervision, and did not follow specific care plan interventions such as increased toileting rounds or ensuring environmental safety (e.g., removing nightstands, keeping doors open for visual checks). On multiple occasions, the resident was found lying on the floor or in bed with saturated linens, indicating a lack of timely assistance with activities of daily living and incontinence care. Staff were observed opening the resident's door to check if he was breathing but did not provide further care or ensure his safety, and transfers were performed without the use of gait belts or proper technique, increasing the risk of falls and injury. Interviews with facility leadership and clinical staff confirmed that there was an expectation for staff to follow all care plan interventions and maintain resident safety, but these expectations were not met. The facility's own policies required prompt response to resident needs, regular fall risk assessments, and implementation of individualized interventions, none of which were consistently followed. The failure to implement and monitor effective fall prevention strategies and provide adequate supervision directly resulted in repeated injuries and placed the resident in Immediate Jeopardy.
Removal Plan
- A fall risk assessment was completed for R2 and placed on 1:1 supervision.
- 1:1 sitters were in-serviced on 1:1 expectation related to coordination of care for R2.
- IDT team reviewed R2 falls to ensure that appropriate current interventions are in place.
- Facility Administrator, DON, ADON, MDS Coordinator were in-serviced on Fall Prevention Policy.
- In-service front-line staff on Fall Prevention Policy and where to verify Care Plan Interventions.
- In-serviced Nursing staff on how to find care plan/fall interventions in EHR. Staff will not work next shift until Fall Prevention In-service is completed.
- An initial audit will be completed of all falls to ensure current interventions are initiated and effective. Care plans will reflect interventions that are effective.
- Initial audit completed of fall risk assessments to ensure that appropriate prevention interventions are in place and care plans are reflecting those interventions.
- A quality assurance tool was implemented: An audit will be completed during clinical meeting to ensure that any fall has a root cause analysis, progressive intervention, and care plan is updated.
- A root cause analysis for Fall Prevention and interventions being placed on care plan and physically in place will be reviewed weekly during Facility Risk Meeting.
- Review of the Fall Prevention Policy.
Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for two residents who were dependent on staff for all activities of daily living and were always incontinent of bowel and bladder. One resident with severe cognitive impairment and multiple diagnoses, including schizophrenia and diabetes, was observed lying in bed for several hours in saturated sheets with urine and feces. Despite staff entering the room multiple times, the resident was not cleaned or checked for incontinence, and the door was repeatedly closed without intervention. The resident confirmed not being cleaned or checked during this period, and staff acknowledged not having time to provide care due to staffing issues. When incontinent care was eventually provided, staff failed to follow proper infection control and hygiene protocols. Hand hygiene was not performed before or after glove changes, and soiled gloves were used to handle clean supplies. The resident's peri-care was incomplete, as the penis and testicles were not cleaned, and soiled clothing was not promptly removed. The process lacked the use of a gait belt for safe transfer, and contaminated gloves were used to search for clean clothing, further breaching infection control standards. A second resident, cognitively intact but dependent on staff for toileting, also received incomplete peri-care. During observed care, staff failed to retract the foreskin to clean the entire penis and did not dry the resident after cleaning. The facility's own policies require residents to be checked for incontinence at least every two hours and for complete peri-care to be provided, including proper hand hygiene and cleaning techniques. Interviews with staff and the DON confirmed expectations for timely and thorough care, which were not met in these instances.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident care for three out of four residents reviewed for infection control. In multiple observed instances, staff members, including CNAs and an LPN, did not perform hand hygiene before donning gloves, between glove changes, or after completing resident care and leaving the room. These lapses occurred during the provision of incontinent care and gastrostomy tube (G-tube) care. One resident with severe cognitive impairment and total dependence for activities of daily living was observed receiving incontinent care from two CNAs who donned gloves without prior hand hygiene, changed gloves multiple times without hand hygiene between changes, and left the room without performing hand hygiene. Another resident, also dependent on staff for ADLs and with a history of bowel and bladder incontinence, received peri-care from CNAs who failed to perform hand hygiene before care, between glove changes, and after care. Additionally, an LPN providing G-tube care to a resident did not perform hand hygiene before donning PPE, between tasks, or after doffing PPE and leaving the room. Interviews with facility staff, including the Director of Nursing and CNAs, confirmed the expectation that hand hygiene should be performed before and after resident care, as well as between glove changes. Facility policies also require hand hygiene at these critical points. However, direct observations and record reviews demonstrated that these protocols were not consistently followed during the care of residents with complex medical needs and high dependency.
Failure to Maintain Resident Room Window in Safe and Homelike Condition
Penalty
Summary
A deficiency was identified when a resident's room window was found to have a hole, allowing flies to enter the room. The resident's daughter reported the issue and took temporary measures by taping the hole and using a fly swatter. The Maintenance Director was unaware of the problem, stating that he typically addresses work orders the same day they are submitted, but no work order had been received for this issue. Upon inspection, the window was found to be inadequately covered with a piece of plexiglass that was not properly secured, leaving visible gaps and allowing outside air to enter the room. The plexiglass was attached with only one screw and loose duct tape, which was no longer effective, resulting in the wind blowing the plexiglass inward. Staff interviews revealed that the process for reporting maintenance issues involves filling out a work order and notifying maintenance, but in this case, the process was not followed, and the deficiency went unaddressed until it was observed during the survey. The facility's policy emphasizes the importance of maintaining a safe, clean, and homelike environment, but the failure to promptly identify and repair the window compromised these standards for the resident involved.
Failure to Conduct Employee Background Checks and Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure a safe environment free from abuse by not performing required background check screenings on current employees who have direct contact with residents. This lapse in screening had the potential to affect all 79 residents in the facility. Specifically, a resident with diagnoses of Bipolar Disorder, Depression, and Anxiety experienced verbal abuse from a staff member. The resident reported that a kitchen staff member used inappropriate language, stating he was going to 'whoop' the resident's ass after the resident complained about cold food. The incident left the resident feeling fear, anger, embarrassment, and a reluctance to leave his room while the staff member was employed. The facility's investigation into the incident was inconclusive, as there were no witnesses and the resident could not recall specific details or the exact date of the event. The staff member in question was suspended immediately and later terminated for safety reasons. During the investigation, it was discovered that the facility could not locate or verify the completion of the staff member's background checks. The administrator acknowledged responsibility for ensuring background checks are completed upon hire, as required by the facility's abuse prevention policy, but was unable to confirm that this had been done for the staff member involved.
Failure to Complete Staff Background Checks Leads to Resident Distress
Penalty
Summary
The facility failed to ensure a safe environment free from actual and potential abuse by not performing required background check screenings on current employees who had direct contact with residents. This lapse affected all 79 residents in the facility, as several staff members, including kitchen, housekeeping, maintenance, and nursing staff, were found to have worked without completed background checks or healthcare worker registry verifications. The administrator acknowledged that background checks were not completed for multiple employees, some of whom had direct access to residents, and that the issue stemmed from a lapse in service by the background check provider due to nonpayment, which was not followed up on by facility leadership. One resident, who has diagnoses of Bipolar Disorder, Depression, and Anxiety, reported experiencing verbal abuse from a kitchen staff member. The resident stated that the staff member used inappropriate language, which caused the resident to feel fear, anger, embarrassment, and reluctance to leave their room while the staff member was employed. The incident was reported and investigated, but the facility was unable to substantiate the allegation due to lack of corroborating evidence and the possibility of a misunderstanding in a noisy environment. However, the resident maintained that the incident occurred and described significant emotional distress as a result. Interviews and record reviews revealed that the facility's policies required background checks and registry verifications to be completed prior to employment, but these procedures were not followed. The administrator admitted responsibility for ensuring these checks were completed and confirmed that several staff members had worked without the required screenings. The medical director emphasized the importance of timely background checks to protect vulnerable residents, and the facility's own policies outlined a zero-tolerance approach to abuse, neglect, and misappropriation of property, which was not upheld in practice.
Removal Plan
- Administrator was in-serviced by the VP of clinical services on background checks and the need to run prior to staff member working.
- Administrator will in-service department heads on ensuring that staff will not work without background check being completed.
- All staff members that are currently on the working schedule have had a background check completed and are eligible to work in a skilled facility.
- Initial audit completed for all current employees, that a background check has been completed.
- Review of current policy and procedure to reflect current practices.
- No staff will work before having a background check.
- A quality assurance tool was implemented: Audit will be completed for new hires to ensure that background check was completed prior to first working day. Administrator and department manager.
- Root Cause Analysis Completed for background checks.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Response to Resident Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff, including both CNAs and nurses, to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. During facility tours, staffing levels were observed to be as low as 2 CNAs and 2 nurses, and later 5 CNAs and 3 nurses, for 81 residents. Residents reported inadequate staffing, with one resident stating that increased use of agency staff indicated a need for more permanent staff. Another resident described multiple falls, including an incident where he was unable to reach his call light after falling, crawled to the hallway without finding staff, and ultimately called 911 for assistance. First responders, including fire and police personnel, reported difficulty locating staff upon arrival, eventually finding a nurse and another staff member outside smoking, both unaware of the resident's situation. Documentation showed that on the day of the incident, scheduled staffing was not met, with fewer CNAs present than planned. The resident involved in the fall was found on the floor with dried blood on his hands, face, and head, and had been attempting to get staff attention with a broken coat hanger. The nurse on duty reported last checking on the resident approximately 45 minutes before first responders arrived but did not enter the room. The facility's staffing policy requires sufficient licensed and unlicensed staff to maintain residents' well-being, but records and staff interviews confirmed that staffing levels were inadequate at the time of the incident.
Failure to Notify Family of Resident Falls
Penalty
Summary
The facility failed to notify a resident's family member of multiple falls experienced by the resident, despite facility policy requiring notification of the physician and responsible party after such incidents. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 6, and multiple diagnoses including catatonic schizophrenia, anxiety disorder, repeated falls, hypertension, major depressive disorder, and type II diabetes. Progress notes documented several falls over a two-month period, but there was no documentation that the family was informed of these events or any resulting injuries. The resident's family member confirmed that they had not been notified of recent falls and only learned of an injury after observing a cut above the resident's eye during a visit and inquiring with nursing staff. Interviews with facility staff indicated that the expectation was to notify families and physicians after a fall, but this was not consistently done for this resident.
Failure to Provide Resident Records to Legal Representative
Penalty
Summary
The facility failed to provide medical records to a resident's legal representative as required. The resident, who had diagnoses including metabolic encephalopathy, epilepsy, vascular dementia, and major depressive disorder, was moderately cognitively impaired at the time of discharge. After discharge, the resident's daughter, who held power of attorney, completed and submitted a HIPAA-compliant authorization form requesting access to the resident's medical records. The form, which specified that the facility must act within 30 days, was handed to a social services staff member, who stated she placed it on the administrator's desk and notified her. Despite this, the administrator and the Vice President of Clinical Services both stated they had never seen the request form and were unaware of its submission. The social services staff member confirmed receiving the form and taking steps to forward it, but no further action was taken, and the records were not provided to the resident's legal representative. This lack of follow-through resulted in the facility's failure to meet the regulatory requirement to provide timely access to resident records.
Failure to Update Care Plans and Complete Fall Risk Evaluations After Resident Falls
Penalty
Summary
The facility failed to implement and/or revise individualized care plans and complete fall risk evaluations for three out of five residents reviewed for accident hazards and supervision. One resident experienced multiple unwitnessed falls over a period of time, including incidents resulting in a hematoma, yet the care plan was not updated with new interventions after several of these falls. The resident's records indicated significant physical impairments, including lower extremity impairment, wheelchair use, and dependence on staff for transfers and toileting, but interventions remained largely unchanged despite repeated incidents. Another resident, with diagnoses including chronic obstructive pulmonary disease and mental health disorders, was identified as at risk for falls in prior evaluations but did not have a current care plan reflecting this risk. After a witnessed fall and an episode of unsteady gait possibly related to alcohol consumption, no new fall risk evaluation was completed. The resident reported frequent outdoor walks and described a recent incident where she tripped outside the facility, but there was no evidence of updated assessment or intervention following this event. A third resident, who was moderately cognitively impaired and required assistance with mobility, was documented as a high fall risk in a previous evaluation, but her care plan did not reflect this status. Family members and staff interviews confirmed that this resident had experienced falls both inside and outside the facility, with at least one incident observed by a family member and reported to emergency services. Staff acknowledged that fall risk care plans and evaluations should be updated after falls, but this was not consistently done. The facility's own policy required post-fall evaluations and care plan updates, which were not followed in these cases.
Mechanical Lifts Not Maintained in Safe Working Condition
Penalty
Summary
The facility failed to maintain mechanical lifts in safe working condition for four residents who required their use. Multiple CNAs reported and were observed struggling to maneuver a mechanical lift whose right leg would swing out unexpectedly without the use of controls, requiring staff to physically kick it back into place. The issue had been ongoing for several weeks, with the word "BAD" written on the malfunctioning leg to indicate its condition. Staff also reported that the lift sometimes failed to move up or down, possibly due to a short circuit, and that the other available lift had similar issues. Residents who depended on the lifts expressed fear and discomfort during transfers, with one resident stating she sometimes could not get out of bed for days due to lift problems, dead batteries, or lack of slings and staff. Despite these ongoing issues, the facility's process for reporting and addressing equipment problems was ineffective. CNAs stated they had notified maintenance, but the administrator was unaware of any work orders for the lifts and had not received reports of the problems. The facility's policy required routine maintenance checks by nursing and maintenance staff to ensure equipment remained in good working order, but this was not followed, resulting in continued use of unsafe equipment and inadequate communication regarding equipment failures.
Failure to Maintain Sanitary and Comfortable Environment Due to Mold and Poor Bathroom Conditions
Penalty
Summary
The facility failed to provide a sanitary and comfortable environment for residents, as evidenced by multiple observations of mold, strong bleach odors, and unclean conditions in several bathrooms and shower areas. Surveyors observed black and green fuzzy substances, identified as mold by staff, on tiles, baseboards, and walls in both men's and women's bathrooms across different hallways. In some areas, tiles were missing and walls were crumbling, and there were strong bleach odors that caused discomfort to surveyors. Toilets were found unflushed, and residents reported infrequent cleaning and persistent mold issues, with some stating they only shower once a week due to the unsanitary conditions. Interviews with residents and staff confirmed ongoing problems with mold, with residents expressing concerns about the cleanliness and odor of the shower rooms. Staff members, including a CNA and the housekeeping supervisor, acknowledged the presence of mold and described efforts to clean it with bleach and water, though the issue was described as longstanding. The facility's policy requires immediate cleaning of mold and mildew with appropriate cleaners, but the observations and interviews indicate that these measures have not been effective in maintaining a sanitary environment.
Failure to Ensure Timely Assessment and Continuity of Care for Resident with Epilepsy
Penalty
Summary
A deficiency occurred when a resident with a known history of epilepsy and complex partial seizures did not receive prescribed anti-seizure medications for four days. The resident's medication orders included Lacosamide and Levetiracetam, both critical for seizure control, which were held from 3/14 to 3/17 following an order from a covering nurse practitioner. This order was based on staff concerns that the resident's daughter may have been providing additional, possibly duplicative, medication doses during a leave of absence, though there was no clear evidence or identification of the medication in question. The decision to hold the medications was made without timely assessment or clarification of the situation, and there was a lack of direct communication with the resident's specialists. The covering nurse practitioner, who was not the resident's regular provider, acted on incomplete information provided by staff, who themselves were uncertain about what medication may have been given by the family. The regular nurse practitioner was on vacation, and upon return, noted that the hold order was based on a possible risk of double dosing, but there was no follow-up or assessment to confirm this before stopping essential medications. During the period when the anti-seizure medications were held, the resident experienced a seizure and required emergency hospital treatment. Hospital records confirmed that the seizure medications had been stopped for several days per facility staff orders. Interviews with facility staff and pharmacy consultants indicated that the lack of timely review and assessment of the medication regimen contributed to the resident's adverse event. The facility did not have a policy on continuity of care to guide staff actions in such situations.
Failure to Administer Anti-Seizure Medications as Ordered
Penalty
Summary
A resident with a history of epilepsy and complex partial seizures did not receive multiple doses of prescribed anti-convulsant medications, specifically oxcarbazepine and lacosamide, as ordered by the physician. The medication administration records showed missed doses of oxcarbazepine on two occasions and missed doses of lacosamide over several days. Documentation indicated that the medications were not available in the facility, and pharmacy records confirmed delays in refilling the prescriptions. The facility's controlled drug receipt and disposition forms corroborated that the resident ran out of lacosamide and did not receive it for several days. During this period without medication, the resident experienced a seizure episode in bed, which lasted 2.5 minutes and included clonic activity and emesis. The resident was found in a post-ictal state, displaying confusion, combativeness, and inability to respond appropriately. Emergency medical services were called, and the resident was sent to the hospital for evaluation and treatment. Interviews with facility staff and pharmacy personnel confirmed that the resident was sub-therapeutic for at least one day and that missing anti-seizure medication in such a case is considered a significant medication error. The facility's policies required that controlled substances be reordered when a four-day supply remained, and that emergency pharmacy services be available 24 hours a day. However, the resident's medication was not reordered in a timely manner, and the emergency kit did not contain the necessary anti-seizure medication. Staff interviews revealed uncertainty about how or if the medication was obtained during the period it was unavailable, and there was no documentation explaining the delay in refilling the medication.
Improper Dishwashing and Food Storage Practices
Penalty
Summary
The facility failed to ensure proper cleaning of dishes and appropriate storage of food, which could potentially lead to foodborne illness affecting all 55 residents. During an observation, a cook was seen washing food residue from a dish in the far-right compartment of a three-compartment sink, then dipping the dish directly into the sanitizing solution in the far-left compartment without rinsing it in between. The middle sink compartment, which should have been used for rinsing, was empty. The cook admitted that the usual process is to wash, rinse, and sanitize dishes, but due to the lack of a stopper for the middle sink, she skipped the rinsing step. Additionally, the facility did not adhere to its policy regarding food storage. In the walk-in refrigerator, containers labeled Super Cereal and Meat Salad were found without a 'Use By' date, despite being dated 11/3/24 and 11/5/24, respectively. In the walk-in freezer, opened and resealed bags of biscuit dough and breadsticks were not labeled or dated upon opening. The dietary manager confirmed that food should be discarded after seven days, aligning with the facility's policy that requires items in refrigerators and freezers to be covered, labeled, and dated with a system to track when to discard perishable foods.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with a history of schizophrenia, depression, anxiety, diabetes, sleep apnea, COPD, and morbid obesity. The incident was reported when the resident claimed to have been hit and scratched by a night CNA. Initial assessments by nursing staff found no signs of injury, and a review of facility cameras showed no interaction between the resident and the accused CNA. Despite this, the facility's investigation was incomplete as the administrator acknowledged not asking the correct abuse-related questions during interviews with other residents. The facility's documentation noted minimal swelling on the resident's face, but the investigation did not substantiate the abuse claim. The resident's statements were inconsistent, and during a police interview, the resident was unresponsive or provided unrelated answers. The facility's abuse prevention policy requires interviews with other residents who have regular contact with the accused, but the administrator admitted to not following this procedure correctly. Consequently, the investigation was deemed insufficient, leading to a deficiency in handling the abuse allegation.
Failure to Address Pain Management in Resident Care Plan
Penalty
Summary
The facility failed to address pain management in the care plan of a resident, identified as R3, who was part of a sample of 43 residents reviewed. Despite the resident being alert and experiencing occasional pain, as documented in the Minimum Data Set (MDS), the care plan dated June 4, 2024, did not include any interventions for pain management. The resident's Physician's Order Sheet from November 2024 listed several pain medications, indicating a need for pain management, yet the care plan lacked any mention of this issue. During an interview on November 13, 2024, the resident reported chronic pain in her legs, knees, and ankles, with a pain level of 6 out of 10. The MDS/Care Plan Coordinator acknowledged that the resident's pain should have been addressed in the care plan with both pharmacological and non-pharmacological interventions. The coordinator was unsure why the pain was not included, suggesting that the resident's multiple hospital discharges over the past six months might have contributed to the oversight. The facility's Comprehensive Care Planning Policy emphasizes the importance of addressing all resident needs, including pain management, in the care plan.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required minimum floor space per resident bed, as mandated by regulations. Specifically, the facility has 30 two-bed resident rooms that only provide 75 square feet per resident bed, falling short of the 80 square feet requirement. These rooms measure 12 feet by 12 feet six inches and are certified for Medicare and Medicaid. Additionally, there are 8 two-bed resident rooms providing 77.5 square feet per resident bed, 3 two-bed resident rooms providing 76.5 square feet per resident bed, and 2 two-bed rooms providing 78.5 square feet per resident bed. These measurements were confirmed through historical data and current room measurements. During observations conducted from November 12 to November 15, 2024, it was noted that 26 out of 55 residents were housed in rooms that did not meet the 80 square feet per resident bed requirement. The facility's Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated November 12, 2024, documents the facility's census as 55. The deficiency affects a significant portion of the resident population, as these rooms are integral to the facility's accommodation of its residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a roach infestation that affected all 56 residents. Observations and interviews revealed that roaches were present in various areas, including the 300-hall, dining room, and individual resident rooms. Staff and residents reported seeing roaches scatter when lights were turned on, indicating a significant infestation problem. The facility's maintenance man, who was responsible for pest control, was terminated for not performing his duties, which contributed to the worsening situation. The pest control company had identified roach activity as early as February and recommended monthly services, but the facility did not follow through due to financial issues. The pest control service was put on hold, and the company was not called back until June. During their visit in June, the pest control technician found roach activity in the kitchen and other areas, confirming the ongoing infestation. The facility's policy required monthly preventative treatments, but this was not adhered to, leading to the deficiency.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
