Fair Havens Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Decatur, Illinois.
- Location
- 1790 South Fairview Avenue, Decatur, Illinois 62521
- CMS Provider Number
- 145422
- Inspections on file
- 67
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 33 (1 serious)
Citation history
Health deficiencies cited at Fair Havens Senior Living during CMS and state inspections, most recent first.
The facility failed to ensure residents were free from physical abuse when one resident became agitated, accused another of being in their home, and struck that resident on the head multiple times with a house slipper in the presence of an LPN, causing fear for the victim. In a separate incident, a resident with schizophrenia and severe cognitive impairment exhibited aggressive behavior toward a roommate with moderate cognitive impairment and multiple medical conditions, with the roommate reporting being hit and the aggressor later admitting to physical contact. These events occurred despite an existing abuse policy defining abuse as any non-accidental physical or mental injury or sexual assault inflicted upon a resident.
A facility failed to ensure that transportation staff were properly trained and competent in using the manufacturer’s 4‑point wheelchair securement system, and a resident’s report that the wheelchair was moving in the van was not acted upon. A resident with multiple comorbidities, impaired mobility, and wheelchair dependence was transported by a driver who had no formal, supervised training and relied only on a checklist. While the van was moving downhill, the resident felt the wheelchair shift and alerted the driver, who reassured the resident and continued driving until the wheelchair tipped forward and the resident fell to the floor, sustaining leg lacerations and fractures. Subsequent observation showed the driver routinely attached securement hooks to wheelchair armrests with twisted straps, contrary to the manufacturer’s requirement to attach to the solid wheelchair frame at the proper angle, and the maintenance director could not accurately demonstrate use of the installed mechanical retractable system. The facility lacked a transportation policy despite a job description assigning responsibility for resident safety during transport, and training documents referencing manufacturer instructions were not effectively implemented.
Two residents engaged in a physical altercation when one went through the other's belongings and attempted to take a remote, resulting in one resident sustaining bloody fingernail marks and superficial scratches to the forearm. An LPN intervened after hearing a commotion, separated the residents, removed a hanger they were both holding, and noted the injuries. A roommate reported that the aggressive resident frequently hits and screams at staff during ADL care. Despite a facility policy requiring identification and care planning for residents with behaviors and triggers that may lead to conflict, no abuse or behavioral assessments, skin assessment, or care plan updates were completed for the involved residents after the incident.
Three residents experienced deficiencies in catheter care and UTI management, including missed catheter changes, lack of urine output monitoring, improper use of PPE during high-contact care, and delays in obtaining and processing urine samples. These failures led to serious complications for one resident, including hospitalization for urosepsis and acute kidney injury.
Two residents experienced a lack of dignity and respect when one, who was severely cognitively impaired and dependent for ADLs, was found lying in bed with her head partially resting against a wall smeared with dried feces, and her representative was not informed of the incident. Another cognitively intact resident, also requiring extensive ADL assistance, reported that staff sometimes took over an hour to respond to call lights for restroom assistance, leading to urinary incontinence and feelings of disrespect. An LPN acknowledged that such delayed responses were unacceptable, and the DON confirmed the substance on the wall was feces, contrary to facility policy requiring residents be treated with respect and dignity.
A resident with lymphedema, cognitively intact and dependent for transfers, was care planned for a full mechanical lift for bed transfers and a sit-to-stand lift only for toileting in the shower room. Staff instead used a sit-to-stand lift to transfer the resident into bed, positioning the resident too close to the metal bed frame so that the back of the right leg struck the frame, causing a large bruise and pain that required medication. Surveyors later observed CNAs using a sit-to-stand lift for toileting with the resident in a bent posture, knees not fully extended, and the chest strap left loose at the resident’s request, while the resident grimaced and complained of pain. Interviews showed inconsistent staff understanding and use of the correct lift type for bed transfers despite care plan and posted instructions.
The facility did not post State Agency contact information and complaint procedures in a clearly visible and accessible location. During a Resident Council meeting, several residents reported they had not seen any information about the State Agency or how to file a complaint. When questioned, the Administrator directed the surveyor to a posting located beyond alarmed entry doors in a foyer and positioned above normal eye level, making it not clearly visible from inside the facility. This deficiency had the potential to affect all 95 residents in the facility.
The facility did not consistently serve meals at its posted scheduled times, despite a written policy and documented schedule indicating specific hours for breakfast, lunch, and dinner. Surveyors observed breakfast and lunch being served later than scheduled on multiple days, and the Certified Dietary Manager acknowledged that breakfast was delayed because staff had not rolled silverware in time. A resident reported that meals are served late all the time, and this pattern had the potential to affect all 95 residents.
Staff failed to consistently use required PPE, post appropriate signage, and ensure PPE availability for residents on Contact Precautions or Enhanced Barrier Precautions. Several residents with indwelling devices, wounds, or multidrug-resistant infections did not receive care according to infection control protocols, and staff were observed providing care without gowns or gloves, not disinfecting shared equipment, and not following proper hand hygiene or medication administration procedures.
An LPN misappropriated one resident’s insulin by withdrawing Novolog and Lantus from that resident’s vials and administering them to another resident whose blood glucose was low and whose own insulin supply was reportedly depleted, despite facility policy prohibiting use of one resident’s medications for another and the availability of a backup medication system that included insulin. In a separate observation, the same LPN had pre-poured multiple oral medications, including pantoprazole, sucralfate, Xarelto, warfarin, and apixaban, for several residents hours in advance of the scheduled med pass, leaving stacked pill cups on the counter, contrary to facility expectations that medications not be pre-poured.
Two residents experienced multiple medication administration errors when an LPN gave scheduled cardiac and other oral medications significantly outside ordered times, used an insulin vial that was not properly labeled with an opened date, and administered insulin from a vial marked with an expired/discard date. In a separate instance, an LPN reported a blood glucose of 49 for a resident who had eaten breakfast without prior glucose monitoring or morning insulin, then borrowed and administered Novolog and Lantus from another resident’s vials and documented these insulins as given well after the scheduled time. Prescribing information cited for Novolog notes it is rapid-acting and should be given within 5–10 minutes of a meal, with hypoglycemia listed as an adverse reaction.
The facility failed to ensure timely administration of multiple cardiac and diabetic medications, resulting in significant medication errors for several residents. An LPN repeatedly administered Hydralazine, Metoprolol, Isosorbide, Sacubitril-Valsartan, and Furosemide hours outside their scheduled times, with some evening doses not given until early the next morning and some doses given too close together. A resident with diabetes had a critically low blood glucose, and the LPN, who was behind on the medication pass, borrowed Novolog and Lantus from another resident’s insulin vials to administer the dose. Another resident had to request her overdue morning CHF medications near midday. Staff acknowledged that the hall has a heavy med pass and that they often exceed the allowed administration window, while a pharmacist confirmed these medications should be spaced at defined hourly intervals.
Surveyors identified multiple deficiencies in medication storage, labeling, and security, including an unlocked medication cart left unattended by an LPN, insulin vials not kept in original packaging or labeled with opened dates, and insulin pens present without corresponding MAR orders for a resident. In medication rooms and carts, expired TB supplies, insulin from a discharged resident, expired saline flushes, and an opened nutritional product without a dated label were found, along with numerous loose, unidentified pills and pill cups containing pre-popped medications such as pantoprazole, sucralfate, Xarelto, warfarin, and apixaban left on counters. A PRN LPN reported being unfamiliar with facility policies related to these practices.
A resident with atrial fibrillation, hypertension, and heart failure had elevated BP readings obtained by an LPN using an electronic cuff, after which Metoprolol Tartrate was administered. Despite facility policy and the resident’s care plan requiring monitoring of vital signs and reporting abnormalities to the physician, there was no documented manual BP reassessment for several hours and no documentation that the elevated BP was reported. The LPN stated she did not follow up because she considered the reading normal for the resident and saw no distress, while the DON indicated she would have expected a manual recheck and physician notification.
A resident with bilateral leg amputations, moderate cognitive impairment, MASD, and an open coccyx wound was not consistently provided with required pressure-relieving interventions. Policy and wound care orders called for turning every two hours in bed, hourly repositioning in a chair, side-to-side positioning, and use of pillows for offloading, but the resident was repeatedly observed lying on his back without pillows and spending extended time in a wheelchair. CNAs reported attempting to reposition the resident and stated the resident refused side-lying due to pain and removed pillows, yet there was no documentation of refusals or notification to nursing or the physician, despite expectations that such refusals be recorded and monitored.
A resident with a gastrostomy tube had an order for Jevity 1.5 Cal, 300 ml bolus feedings every six hours, but an LPN administered 600 ml using a syringe with a plunger instead of gravity flow, contrary to facility policy and the physician’s order. During the procedure, the LPN intermittently laid the unclamped G-tube on the resident’s lap, causing feeding to leak onto the resident. The LPN later acknowledged the correct ordered volume and that the tube had been left unclamped, and the DON confirmed that enteral feeding volume and method must follow the physician’s order and be given by gravity flow.
The deficiency concerns the facility’s failure to properly offer and document pneumococcal vaccinations for two residents reviewed for immunizations. One resident with moderately impaired cognition did not recall being asked about the pneumonia vaccine, and her POA remembered only influenza and COVID-19 vaccines being offered; the resident’s vaccination authorization form was marked as a refusal but lacked a date. Another resident with intact cognition reported that only influenza and COVID-19 vaccines were offered and stated she would like the pneumonia vaccine. An LPN admissions coordinator reported educating residents and families about vaccines and said one resident had declined the pneumonia vaccine, but acknowledged the refusal form should have been dated. The DON stated that merely asking residents on admission if they want the pneumonia vaccine is not sufficient, despite a facility policy requiring adherence to a pneumococcal vaccine protocol and documentation of education and refusals.
A significant German cockroach infestation was observed in food service areas, including the staff lounge, kitchen, and steam table line, with live and dead insects found in drawers, cabinets, and a refrigerator with a broken seal. Staff confirmed the ongoing issue and that utensils from infested areas were used to plate meals. Pest control efforts and sanitation practices were inadequate, failing to meet facility policies and potentially affecting all residents.
A CNA, who was also an LPN student but not yet licensed, assisted an LPN by handing out medications to several residents in the hallway. The CNA did not prepare the medications but distributed them as directed by the LPN, despite facility policy and job descriptions restricting medication administration to licensed personnel or qualified medication aides.
The facility did not maintain an effective pest control program, resulting in the presence of cockroaches in the kitchen, serving areas, and resident rooms. Staff and a resident confirmed sightings of live and dead cockroaches, and surveyors observed evidence of infestation in multiple areas. Pest control efforts were inconsistently documented, and the issue persisted over several months.
A dependent resident with severe cognitive impairment did not receive scheduled showers, and there was no documentation of showers, refusals, or alternative hygiene care. Staff interviews and family reports confirmed the lack of hygiene care, and the DON acknowledged missing documentation, resulting in the resident not receiving appropriate personal hygiene.
A resident with multiple psychiatric diagnoses experienced a lapse in receiving a prescribed controlled substance (Lunesta) due to the facility's inability to obtain a timely signed prescription from the psychiatric provider. Nursing staff made repeated attempts to secure the prescription, and an alternative medication was administered in the interim. The resident was aware of the missed doses and reported that the substitute medication was less effective.
A resident with multiple medical conditions, including a femur fracture and chronic leg ulcers, was administered Hydromorphone for pain at intervals shorter than the physician-ordered six hours on several occasions. This was confirmed by the DON and corporate clinical staff through review of controlled drug records.
A resident with multiple chronic conditions received PRN Hydromorphone as ordered, with administration documented on the controlled drug record. However, nursing staff failed to record these administrations on the Medication Administration Record, as required by facility policy and physician orders.
A resident with chronic ulcers and a femur fracture did not receive wound dressing changes as ordered, resulting in saturated dressings and soiled bedding. Nursing staff documented the treatment as completed when it had not been done, and the facility's policy for prompt and accurate documentation was not followed.
Two residents with known fall risks were left unsupervised during activities requiring staff oversight—one during a shower and another while smoking outside—resulting in falls. Both residents had documented needs for supervision due to physical or cognitive impairments, but staff failed to remain present as required, leading to unwitnessed accidents.
A resident with an indwelling urinary catheter for obstructive and reflux uropathy experienced pain and frequent urine leakage due to the catheter not being secured with a leg strap or adhesive tape, as required by facility policy. The resident's bed linens were found wet, and the resident reported ongoing discomfort and requests for proper catheter securing that were not addressed. Staff confirmed the absence of a leg strap and the need to notify nursing about the resident's pain.
A resident with severe cognitive impairment and high assistance needs was found to have accumulated urine-soaked clothing on the floor of her room, resulting in strong odors. Staff acknowledged lapses in timely laundry removal and assistance with toileting, and a family member reported multiple bags of soiled clothes and a saturated recliner. Facility policy requiring a clean and odor-free environment was not followed.
A resident dependent on staff for hygiene due to paraplegia and weakness was left in soiled conditions for an extended period after requesting incontinence care. Multiple staff, including CNAs and an RN, were aware of the resident's request but did not provide timely assistance, instead prioritizing other tasks. Facility policy requiring prompt response to resident needs was not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Two residents experienced a lack of dignity due to staff actions: one was removed from the facility during a meal without explanation and had personal belongings handled disrespectfully, while another was left with a washcloth in an incontinence brief after rushed care for dialysis, resulting in humiliation when the odor was noticed by others. Both incidents involved failures in communication and respect for resident dignity.
A resident with a history of alcohol abuse and multiple medical conditions was verbally abused and threatened with bodily harm by a roommate after being moved into a shared room. The incident, which was witnessed by a housekeeper, occurred despite facility policies requiring identification and care planning for residents at risk of abuse.
Multiple residents reported receiving cold and unappetizing meals due to delays in meal tray delivery and lack of temperature maintenance, as confirmed by direct observations and resident council meeting minutes. Residents with varying cognitive abilities expressed dissatisfaction, and some avoided eating meals or requested reheating due to the persistent issue.
The facility did not maintain an adequate supply of linens, with only a portion of laundry equipment functioning and limited towels and washcloths available. Staff reported frequent linen shortages and difficulty keeping up with laundry due to understaffing. Multiple residents stated they had not received scheduled showers, citing a lack of linens and laundry staff as the reason.
Multiple residents did not receive showers as required, with observations showing poor hygiene such as food-stained clothing and oily hair. Residents reported not receiving showers for over a week, and staff interviews revealed ongoing shortages of linens and housekeeping staff, leading to missed ADL care. Facility policy requires showers twice weekly, but documentation and resident statements confirmed this was not met.
The facility did not consistently perform or document shift-to-shift controlled medication counts as required, with missing or incomplete count sheets and lack of dual nurse signatures. Several residents received controlled medications that were not properly documented on the MAR, and in some cases, medications were administered without verifying active orders in the electronic record. Staff confirmed these discrepancies and the DON acknowledged that required documentation was missing or incomplete.
Multiple residents experienced significant medication errors due to the facility's failure to administer medications as ordered, delays in reordering controlled substances, and lack of timely physician notification when medications were missed or delayed. LPNs and the DON confirmed issues with medication supply, late administration, and insufficient documentation, affecting pain management, blood pressure control, and diabetes care.
The facility did not ensure proper storage and timely destruction of controlled medications for two residents. In one case, Morphine was found outside the locked controlled compartment, and in another, discontinued Norco tablets remained in the medication cart. Staff interviews and record reviews confirmed these lapses, and required shift change documentation was incomplete.
A LTC facility experienced a 13.51% medication error rate due to failures in administering medications as per physician orders. Errors included unavailability of medications, incorrect dosages, and failure to follow administration instructions. These issues affected five residents and were contrary to the facility's Medication Administration Policy.
A resident with paraplegia felt intimidated and verbally abused by an RN who misheard a conversation and aggressively confronted the resident. Despite reporting the incident to the Administrator-In-Training, the resident's concerns were dismissed, and the RN continued to work, exacerbating the resident's fear and anxiety.
A resident reported feeling threatened and verbally abused by an RN, but the facility failed to investigate the allegation or protect residents. The RN continued to work without suspension, and no evidence of an investigation was found in the facility's records, violating the facility's Abuse Prevention Program policy.
A resident reported feeling threatened and verbally abused by an RN to the Administrator-In-Training, who failed to report the allegation to the state agency as required by the facility's policy. The policy mandates immediate reporting of abuse allegations to the Illinois Department of Public Health, but the facility's records showed no evidence of such reporting.
The facility failed to maintain functional and homelike shower rooms, affecting all 102 residents. The 200 and 300 hall shower rooms were in disarray with construction debris and equipment, and had been shut down for safety reasons. The Maintenance Director stated repairs had been ongoing for six months without completion. Residents expressed dissatisfaction with the condition of the shower rooms, noting mold, insects, and construction debris, and reported having to use other halls' shower rooms, which were also in poor condition.
The facility's dishwasher failed to reach the required 180 F for sanitizing dishware, with observed temperatures ranging from 156 F to 178 F. The Dietary Manager acknowledged the issue, and the Maintenance Director had contacted a service company for repairs. The Administrator was unaware of the problem until the survey and noted the need for improved communication among staff. The facility's contract with a specific service company delayed immediate repairs.
The facility, with a 154-bed capacity, failed to employ a qualified Social Worker, impacting 102 residents. The Administrator confirmed the absence of a degreed Social Worker, and the former Social Services Director, now Business Office Manager, lacked the necessary qualifications. The staff roster shows the Social Services position is vacant.
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches and sewer flies in the kitchen area. The dishwasher area was saturated with water due to leaks, and a two-compartment sink was leaking sewage water onto the floor. The Dietary Manager was aware of the issue, and a maintenance work order had been submitted. Resident complaints about fruit flies were documented in the Resident Council Meeting Minutes.
The facility's door alarms and monitoring systems were not functioning properly, affecting all 102 residents. The Maintenance Director admitted the system failed to emit sounds when doors were opened, and screens at nurse stations were not displaying the facility map. Some doors lacked functional alarms and could be opened easily. The Administrator acknowledged the issue and the lack of communication and action to fix it. Staff were not always present in areas where residents could exit unsupervised, and they did not respond to door ajar announcements due to non-functional screens.
The facility failed to accurately assess and document the smoking status of three residents, leading to discrepancies in their MDS and care plans. The smoking schedule listed them as smokers, but their MDS inaccurately documented them as non-smokers. One resident's care plan lacked a focus area for smoking, and another's smoking assessment was incomplete. The Infection Preventionist/Wound Nurse confirmed these discrepancies.
The facility failed to timely assess residents for pressure ulcer risk and complete treatments as ordered, affecting three residents. Documentation was missing for pressure ulcer treatments on the sacrum, buttocks, and right heel, as well as daily skin checks. The facility's policy requires Braden Assessments upon admission, weekly for a month, then quarterly, but these were not updated. Additionally, treatment documentation was not completed as required.
The facility failed to employ a full-time DON, affecting all 109 residents. The Administrator confirmed the absence of a full-time DON for six months, and during the survey, no DON was present. The CMS-802 Matrix form documents 109 residents in the facility.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents. In one incident, an abuse investigation dated 3/15/2026 at 8:45 PM documented that one resident (R3) became agitated with another resident (R10), accusing R10 of being in R3's house, and then began hitting R10 on the head with a shoe. A Licensed Practical Nurse (V10) witnessed R3 hitting R10 on the head with the shoe. During an interview on 3/24/2026 at 12:46 PM, R10 recalled being hit a few times with a house slipper by R3, stated that R3 was accusing R10 of being in R3's home, and reported that this interaction was frightening. The Administrator (V1) later confirmed that, based on interviews with R10 and V10, it was determined that R3 did hit R10 multiple times in the head with a shoe and that the allegation of abuse was substantiated. In another incident, the facility’s abuse investigation dated 2/9/2026 at 8:45 PM documented that resident R7 had aggressive behaviors toward resident R6, with R6 reporting that R7 hit R6 with a closed fist. R6’s care plan shows an admission date of 10/25/2024 and diagnoses including poisoning by hydantoin derivatives, essential hypertension, and cerebral infarction, with a Minimum Data Set (MDS) indicating moderate cognitive impairment. R7’s MDS documents severe cognitive impairment, and R7’s care plan lists diagnoses including schizophrenia, dysphagia (oropharyngeal phase), constipation, hyperlipidemia, and benign prostatic hyperplasia. On 3/23/2026 at 10:55 AM, R6 stated having been hit by a roommate in the past but could not recall the specific date, while R7 was deemed non-interviewable due to severe cognitive decline and dysphasia. On 3/23/2026 at 3:15 PM, an LPN (V7) reported that R7 admitted to hitting R6 on the arm when questioned on 2/9/2026. The facility’s abuse policy dated 10-2022 defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.
Failure to Train Van Staff on Wheelchair Securement Leads to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure transportation staff were properly trained according to the wheelchair securement system manufacturer’s instructions and to respond appropriately when a resident reported wheelchair movement in the transport van. One resident, R3, had a care plan documenting multiple diagnoses including acute on chronic diastolic congestive heart failure, morbid obesity, hypertension, localized edema, depression, anxiety disorder, heart disease, and chronic kidney disease. R3 had weakness, bilateral lower extremity edema, impaired mobility, used a manual wheelchair for locomotion, and required staff assistance for activities of daily living and transfers. On the day of the incident, R3 was being transported in the facility’s van when the wheelchair moved and tipped forward while the van was in motion. According to the facility’s investigation and staff interviews, the van driver (V13) transported R3 to the van in a wheelchair, applied wheelchair restraints and a lap belt, and began driving down a hill away from the facility. Shortly after the van began moving, R3 felt the wheelchair move and alerted the driver that the wheelchair was moving; the driver reportedly told R3 that she would be okay and continued driving. The driver then heard R3 scream, looked in the rearview mirror, and saw the wheelchair tipped forward with R3 leaning forward and attempting to brace herself. The driver parked, assessed the situation, then drove the van back around the parking lot to the main entrance to obtain help. When the DON (V2) and an LPN (V11) entered the van, they observed the wheelchair tipped forward, R3 on the floor with the left leg under her, blood present, and the restraint straps still attached and pulled taut, making it difficult to free R3 from the wheelchair and seatbelt. Emergency department and orthopedic records document that R3 fell out of the wheelchair in the transport van, sustained multiple lacerations to the lower extremities, and suffered fractures of the left tibia and fibula, including a proximal tibia fracture, fibular head fracture, distal fibula fracture with extension to the ankle syndesmosis, and an anterior inferior tibiofibular avulsion fracture. Interviews and record review showed that the van driver stated she was not formally trained on driving the van or securing residents, had only received a safety checklist, and had no supervised training or daily safety checklist for the van. The maintenance director (V5) claimed to have trained the driver and had signed training checklists, but the forms were photocopied, lacked the trainee’s signature, and the driver denied receiving the post-incident training documented. Observation of the driver securing another resident (R8) in the van showed the J-hooks of the mechanical retractable system attached to the wheelchair armrests at an improper angle with twisted straps, and another resident (R12) reported the driver had repeatedly used armrests as anchoring points. The manufacturer’s manual and the facility’s own training checklist required attachment of tie-down hooks to a solid wheelchair frame at an approximate 45-degree angle, with no twisting of straps, and specified that the system should only be operated by individuals who fully understand its use, requirements that were not met in this case. Additional interviews and document review revealed that the facility did not have a transportation policy at the time of the incident, despite the transportation aide job description stating that the purpose of the role was to provide safe and timely transportation in compliance with federal, state, local, and corporate requirements and to assume responsibility for residents’ safety while transporting. The driver’s training forms referenced following the manufacturer’s guide for specific instructions on how to secure the wheelchair and client and included a detailed checklist for proper wheelchair securement and patient restraint, including inspection of straps, correct floor anchor positioning, attachment to appropriate anchor points on the wheelchair frame, and avoidance of strap twisting. However, the observed practices of the driver and the maintenance director’s inability to accurately demonstrate use of the specific mechanical retractable system in the van showed that these procedures were not effectively taught or followed. These combined failures in training, policy, and response to the resident’s report of wheelchair movement led to R3 sliding forward in the wheelchair, the wheelchair tipping forward, and R3 falling onto the van floor, resulting in significant injury.
Removal Plan
- Conducted in-service education on proper securing of resident wheelchairs in the transportation van, including the facility policy, for the approved transportation drivers and the maintenance director
- Utilized a video training about the securement straps and seat belts in the transportation van for the approved transportation drivers and the maintenance director
- Conducted return demonstrations for the approved transportation drivers and the maintenance director
- Developed a facility policy for securement of wheelchairs in the transportation van
- Reviewed the job description for the transportation drivers
- Developed a list of approved transportation drivers
- Conducted a Quality Assurance Meeting to discuss the Immediate Jeopardy citation, needed training, proficiency checklist, list of approved drivers, review of transportation aide job description, development and corporate approval of facility policy, and abatement plan
- Conducted audits for residents utilizing the facility van to be transported to appointments
- Confirmed the transportation drivers completed proper demonstration for securement technique of an occupied wheelchair into the facility transportation van
Failure to Prevent and Assess Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, as required by its Abuse Prevention and Reporting policy. The policy states that residents have the right to be free from abuse, including physical abuse such as hitting, slapping, pinching, and controlling behavior through corporal punishment, and that staff must identify residents with increased vulnerability, triggers, and behaviors that might lead to conflict through admission assessments, comprehensive care plans, and MDS assessments. Staff are required to use the care planning process to identify problems, goals, and approaches to reduce the chances of abuse and to monitor and update these on a regular basis. In this case, the facility did not complete abuse or behavioral assessments after a resident-to-resident altercation, and there was no skin assessment or care plan update or revision for the injured resident following the incident. On the date of the incident, an LPN heard a commotion in a shared room and observed both roommates physically touching each other, with one resident in a wheelchair and the other on the bed. One resident complained that the other was on her side of the room and bothering her belongings, while the other responded confrontationally. The LPN removed a hanger both residents were holding, separated them into the hallway, and then observed that one resident’s forearm was bloody, with apparent nail marks and superficial scratches that were cleansed and treated with triple antibiotic ointment. Interviews indicated that one resident had a history of aggressive behaviors and that the altercation occurred when one resident was going through the other’s personal belongings and wanted the remote, leading to the scratching. Another roommate reported that the aggressive resident hits and screams at staff during ADL assistance. The DON confirmed that the injured resident received fingernail scratches to the right forearm and that no behavioral services, behavioral assessments, or abuse assessments were completed for the aggressive resident after the interaction.
Failure to Provide Appropriate Catheter Care and Timely UTI Management
Penalty
Summary
The facility failed to provide appropriate and hygienic catheter care, monitor urinary catheter output, and timely treat symptoms of urinary tract infection (UTI) for three residents. For one resident with a history of multidrug-resistant infections and moderate cognitive impairment, staff did not consistently change the urinary catheter as ordered, with a gap of several months between documented changes. There was also a lack of routine monitoring and documentation of urinary output. Staff did not follow Enhanced Barrier Precautions (EBP), as they failed to wear gowns during high-contact care activities, including catheter care and transfers, despite posted signage and available PPE. Catheter care was not performed according to protocol, with incomplete cleaning of the catheter tubing. These failures led to the resident developing urinary retention, UTI, urosepsis, acute kidney injury, and hydronephrosis, requiring hospitalization and urinary stent placement. Another resident was observed with urinary catheter tubing dragging on the floor during transfer, and the collection bag was held above the level of the bladder, causing urine to drain back toward the bladder. The clip intended to keep the tubing off the floor was not used. Staff again did not wear gowns during high-contact care, despite EBP signage. The resident's urine was noted to be cloudy with sediment, and subsequent urine cultures revealed significant bacterial growth, including ESBL E. coli and vancomycin-resistant Enterococcus faecalis. A third resident experienced frequent UTIs, and there were delays in obtaining and processing urine samples after symptoms were reported. Documentation showed a lag of several days between the onset of symptoms and the collection and processing of urine samples, with no evidence that the initial sample was sent to the laboratory. Orders for antibiotics were not received until nine days after symptom onset, and there was a lack of documentation regarding the handling of urine specimens. These actions and inactions contributed to the deficiencies identified in the care of residents with urinary catheters and UTIs.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to protect the dignity and psychosocial well-being of two residents by not ensuring they were treated with respect and assisted promptly with personal needs. One resident, who was severely cognitively impaired, required maximum assistance with activities of daily living and had a diagnosis of dementia. This resident was observed lying in bed on the left side with the right side of the head positioned partially on a pillow and partially against a wall. The wall next to the bed had noticeable dried brown hand wipes on the white surface, which the Director of Nursing identified as feces, and stated that the resident's head was lying in the feces. The resident’s power of attorney later reported that no one from the facility had contacted them about the incident and stated that the resident would not have appreciated having her head lying in feces. Another resident, who was cognitively intact and required maximum assistance with activities of daily living, reported that when needing to use the restroom, the call light system was activated but at times it took over an hour for staff to respond. The resident stated that this delay resulted in urinary incontinence and made the resident feel disrespected. A Licensed Practical Nurse confirmed that all call lights should be answered as quickly as possible, that a response time of over an hour was not acceptable, and that this resident was alert and would know when restroom assistance was needed. The facility’s policy stated that every effort would be made to assist each resident in exercising their rights to ensure they are always treated with respect, kindness, and dignity.
Improper Use of Sit-to-Stand Lift Causes Resident Leg Bruising
Penalty
Summary
A deficiency occurred when staff failed to follow the resident’s assessed transfer status and the facility’s Safe Lifting and Movements of Residents policy, resulting in improper use of a sit-to-stand lift and injury. The cognitively intact resident, who had lymphedema in both legs and was dependent on staff for chair, bed, and toilet transfers, was care planned to use a full mechanical lift for transfers to and from bed and a sit-to-stand lift only for toileting in the shower room. Despite this, CNAs used a sit-to-stand lift to transfer the resident into bed, positioning the resident too close to the metal bed frame, which led to the back of the resident’s right leg striking the frame. The resident subsequently developed a baseball-sized blue/purple bruise and hardening on the back of the right calf/knee area and reported new right leg pain that required pain medication. During surveyor observation, CNAs were again seen using a sit-to-stand lift for toileting, with the resident bearing weight in a bent posture, knees not fully extended, and the chest strap left loose because the resident reportedly did not like it tightened. The resident grimaced, moaned, and complained of pain during these transfers and pointed out the bruise, stating that staff had banged her leg on the bed and that it hurt. Interviews and record review confirmed that some staff used a full mechanical lift and others used a sit-to-stand lift for bed transfers, and that at least one CNA had recently started working on the hallway and had been told the resident used a sit-to-stand lift, contrary to the care plan and posted instructions in the room. These actions and inconsistencies in following the documented transfer requirements led to the resident’s bruising and pain.
State Agency Complaint Information Not Posted in an Accessible Location
Penalty
Summary
The facility failed to post the name, address, and telephone number of the State Agency, including information on how to file a complaint, in an accessible location within the facility as required by F575. The facility’s Long-Term Care Facility Application for Medicare and Medicaid dated 12/07/2025 documented a census of 95 residents. During a Resident Council meeting, multiple residents reported they had not seen any information posted in the facility related to the State Agency or how to file a complaint, and several other residents present agreed they were not aware that such information was posted. When the surveyor asked the Administrator about the posting, the Administrator directed the surveyor to the front entrance, past alarmed entry doors, into a foyer area where the State Agency complaint contact information was displayed at a height above the surveyor’s eye level while standing, and the information was not clearly visible from inside the facility. This failure had the potential to affect all 95 residents residing in the facility, as the required State Agency contact information and complaint procedure details were not posted in a clearly visible and accessible location within resident areas.
Failure to Serve Meals at Posted Scheduled Times
Penalty
Summary
The facility failed to serve meals at the posted and scheduled times as outlined in its dietary policy and application for Medicare and Medicaid, which state that three well-planned meals will be served at regularly scheduled hours of 7:30 a.m. for breakfast, 11:30 a.m. for lunch, and 5:00 p.m. for dinner. Record review confirmed these scheduled times, and the Certified Dietary Manager verified them during interview. However, surveyor observations showed breakfast service began at 8:10 a.m. and lunch at 12:15 p.m. on one day, and breakfast began at 8:17 a.m. on another day, all later than the posted times. During interview, the Certified Dietary Manager stated that breakfast was late being served because no staff had rolled silverware, which was needed before serving the meal. A resident reported that meals are served late all the time. This failure to adhere to scheduled meal times had the potential to affect all 95 residents in the facility. The deficiency centers on the inconsistency between the facility’s documented dietary policy and actual practice, as evidenced by delayed meal service on multiple observed days, staff acknowledgment of operational issues (lack of rolled silverware) causing delays, and resident report of chronic lateness of meals.
Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for residents requiring Contact Precautions and Enhanced Barrier Precautions (EBP). Multiple instances were observed where staff did not wear required personal protective equipment (PPE), such as gowns and gloves, when providing care to residents with indwelling devices, wounds, or infections with multidrug-resistant organisms. In several cases, signage indicating the need for isolation or EBP was missing or not updated, and PPE supplies were not readily available outside resident rooms. Staff members were observed entering rooms and providing care without donning appropriate PPE, and some staff expressed uncertainty about which residents required precautions or the correct use of PPE. Specific residents with documented infections or indwelling devices, such as urinary catheters or wounds, were not consistently placed on the appropriate precautions. For example, one resident with a positive urine culture for ESBL E. coli and Providencia stuartii remained in a shared room without consistent use of Contact Isolation by staff, despite ongoing physician orders. Other residents with indwelling catheters or wounds did not have EBP signage posted, and staff did not use gowns and gloves during high-contact care activities, including catheter care and transfers. In some cases, staff were observed using shared equipment, such as vital signs machines, without disinfecting them between residents, and wearing gowns outside resident rooms contrary to protocol. Medication administration practices also failed to meet infection control standards. An LPN was observed preparing and administering insulin without disinfecting vial stoppers, performing hand hygiene, or wearing gloves. The LPN also placed an uncapped syringe in her pocket before administering insulin. Facility policies required hand hygiene before and after medication administration, disinfecting vial tops with alcohol, and proper disposal of needles, but these procedures were not followed. These failures were confirmed by interviews with nursing leadership and staff, who acknowledged the lapses in infection prevention and control practices.
Misappropriation and Improper Handling of Resident Medications
Penalty
Summary
The deficiency involves the misappropriation and improper use of resident medications and failure to follow medication administration policies. A facility policy stated that drugs ordered for one resident must not be used for another, and the abuse prevention program defined misappropriation of resident property as wrongful use of a resident’s belongings without consent. Despite this, an LPN reported that after obtaining a blood glucose of 49 for one resident, she determined that the resident was out of insulin and decided to “borrow” insulin from another resident, acknowledging she had been taught not to do so. She withdrew 2 units of Novolog and 10 units of Lantus from one resident’s insulin vials and administered them to another resident, even though the facility had a backup medication system that included insulin. Prescribing information for Novolog specified that insulin vials should not be shared between different patients, even with different needles. The deficiency also includes improper medication handling and preparation practices. During observation of medication storage on one hall, four pre-poured medications in pill cups were found stacked on the counter, intended for a later medication pass. The LPN on duty stated she was PRN and not aware of the facility’s policies or procedures and confirmed that the pre-poured medications were for multiple residents, including pantoprazole, sucralfate, Xarelto, warfarin, and apixaban scheduled for administration several hours later. The DON later confirmed with the LPN that she had pre-poured these medications and stated that medications should not be pre-poured, indicating that the observed practice was inconsistent with facility expectations and contributed to the identified deficiency.
Medication Administration Errors and Improper Insulin Practices
Penalty
Summary
The deficiency involves failure to administer medications as ordered and to maintain an acceptable medication error rate, resulting in 8 errors out of 25 opportunities (32%) for two residents. For one resident, an LPN prepared and administered multiple morning oral medications, including Hydralazine, Potassium Chloride, Torsemide, and Oxybutynin, significantly later than the scheduled 9:00 AM time, with actual administration occurring between 11:38 AM and 11:41 AM. The same resident’s lispro insulin vial was not in its original box, was not properly labeled with a dispensed or opened date, and bore a handwritten date next to the expiration/discard date; the LPN administered 2 units of lispro insulin from this vial. The resident’s blood pressure readings taken shortly thereafter were elevated, and the LPN administered Metoprolol Tartrate at 12:00 PM. The pharmacist later stated that Hydralazine should be spaced approximately 6–8 hours apart and Metoprolol Tartrate 10–12 hours apart, and that administering these medications too close to the next scheduled dose could increase medication effects, while late doses could result in elevated heart rate and blood pressure as the medication’s effects diminish. For another resident, the LPN stated that the resident’s blood glucose was 49 and that the resident was out of insulin. The LPN withdrew 2 units of Novolog and 10 units of Lantus from another resident’s insulin vials and administered them to this resident, despite acknowledging she had been taught not to borrow medications. The LPN also stated she was behind on 8:00 AM medications, including this resident’s insulin, and that the resident had eaten breakfast around 7:00 AM without having blood glucose checked or morning insulin administered beforehand. The medication administration record showed that Lantus 10 units subcutaneously daily at 8:00 AM was actually given at 10:52 AM, and Novolog per sliding scale scheduled for 8:00 AM was given at 10:48 AM. The Novolog prescribing information indicates it is a rapid-acting insulin that should be administered within 5–10 minutes of a meal, and adverse reactions include hypoglycemia.
Significant Medication Timing Errors and Improper Insulin Borrowing
Penalty
Summary
The deficiency involves the facility’s failure to administer cardiac and related medications within required timeframes, resulting in significant medication errors for multiple residents. One resident received Hydralazine, ordered three times daily at 9:00 AM, 1:00 PM, and 9:00 PM, at 11:38 AM and 2:08 PM on one day, and at 11:10 AM and 2:30 PM on another day, outside the one-hour before/after window stated by the nurse. The same resident’s Metoprolol Tartrate, ordered at 9:00 AM and 8:00 PM, was administered at 12:02 PM for the morning dose, and the evening doses on two consecutive days were not given until early the following mornings (12:35 AM and 4:17 AM). During observation, the LPN administered the resident’s morning oral medications, including Hydralazine, then obtained elevated blood pressure readings and administered Metoprolol at noon, confirming that medications are supposed to be given within one hour of the scheduled time. Another resident with diabetes had a blood glucose of 49, and the LPN stated the resident was out of insulin and proceeded to borrow Novolog and Lantus from another resident’s vials before administering them, while also being behind on 8:00 AM medications for several residents as indicated by overdue (red) medication alerts. This resident’s Isosorbide, Metoprolol Tartrate, and Hydralazine were repeatedly administered late or too close together, including an evening Hydralazine dose given less than five hours before the next morning dose and other doses given many hours after the scheduled times. A third resident reported around midday that she had not yet received her morning medications; record review showed her Sacubitril-Valsartan and Furosemide, both ordered for CHF, were administered several hours late on multiple days, with some evening doses given in the early morning hours. Staff, including the LPNs and pharmacist, confirmed that the unit has a heavy medication pass, that the nurse often runs past the allowed medication window, and that these medications should be spaced at specific hourly intervals to avoid excessive or diminished effects.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
The deficiency involves multiple failures in medication storage, labeling, and security. An LPN left the 200-unit medication cart unlocked and unattended, contrary to the facility’s policy requiring carts to be locked when not in use. During a medication pass, a resident’s lispro insulin vial was observed not in its original box and without an opened date, bearing only a handwritten expiration/discard date. The same cart contained two Tresiba insulin pens labeled for another resident with dispensed dates but no corresponding medication order on that resident’s MAR. The resident receiving lispro insulin had an order for sliding scale insulin three times daily, and the manufacturer’s instructions require opened vials to be discarded after 28 days of use. Additional deficiencies were identified in the 300 Hall medication room and carts. In the medication refrigerator, opened house stock TB supplies and insulin from a discharged resident were found past their expiration dates, along with expired prefilled normal saline flush syringes. An opened container of 2 Cal Vanilla Medication Pass on top of the refrigerator lacked an expiration date. The 300 Hall medication cart contained approximately 50 loose pills scattered in a drawer. In the 200 Hall medication storage area, unidentified loose pills were found in a pill cup inside a cabinet, and multiple pill cups containing pre-popped, resident-specific medications (including pantoprazole, sucralfate, Xarelto, warfarin, and apixaban) were observed lying on the counter. A PRN LPN working on the unit stated she was not aware of the facility’s policies or procedures regarding these practices.
Failure to Reassess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to reassess and report an elevated blood pressure for a resident with significant cardiac diagnoses. The facility’s Acute Changes in Condition Clinical Protocol requires nurses to monitor and report changes in condition, including vital signs, to the physician and to make pertinent observations and collect appropriate information before contacting the physician. The resident’s active care plan, which includes diagnoses of atrial fibrillation, hypertension, and heart failure, directs staff to monitor vital signs and report abnormalities to the physician. On the specified date and time, an LPN obtained blood pressure readings of 162/121 in the left arm and 170/100 in the right arm using an electronic blood pressure cuff and then administered Metoprolol Tartrate 50 mg. The resident’s blood pressure log for the month shows readings ranging from 130/72 to 170/100, with a 170/100 reading documented shortly after the elevated readings were obtained. However, there is no documentation that the resident’s blood pressure was reassessed after the initial elevated readings until several hours later, nor is there documentation that the elevated blood pressure was reported to the physician. In an interview, the LPN stated she did not perform any follow-up on the blood pressure because she considered it normal for the resident and observed no signs of distress, and she acknowledged that she did not reassess the blood pressure manually. The DON stated she would have expected the nurse to recheck the blood pressure manually and, if it remained elevated, to notify the physician.
Failure to Implement Repositioning and Offloading for Resident With MASD and Coccyx Wound
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure-relieving interventions and repositioning for a resident with moisture-associated skin damage (MASD) and an open coccyx wound. The facility’s pressure ulcer prevention policy requires residents to be repositioned at least every two hours in bed and every hour when in a chair. Despite this, the resident was repeatedly observed lying on his back in bed on an air mattress without pillows for offloading or side positioning, and there was no documentation of repositioning refusals. The resident, who has bilateral leg amputations, moderate cognitive impairment, and is dependent on staff for bed mobility and transfers, reported that he has sores on his buttocks that began in the hospital and that staff do not reposition him often enough or place him on his side. Clinical documentation on the Wound Evaluation & Management Summary identified partial-thickness MASD wounds and an open area on the coccyx, with recommended interventions including offloading the wound, side-to-side positioning, and repositioning per facility protocol. CNA task charting also prompted turning and repositioning every two hours and the use of pillows for offloading. However, observations showed the resident remained on his back for extended periods in both bed and wheelchair, and CNAs acknowledged that the resident was on his back and reported he refused side-lying due to pain and removed pillows. The wound nurse stated the resident should be turned every two hours with limited sitting time, that CNAs should notify the nurse and physician and document refusals, and that behavior monitoring should be implemented, but she was unable to find any documentation of refusals of care in the medical record.
Improper Bolus G-Tube Feeding Administration and Failure to Follow Physician Order
Penalty
Summary
The facility failed to administer a gastrostomy tube feeding according to the physician’s order and facility policy for one resident receiving bolus tube feedings. The facility’s policy for gastric tube feeding via syringe (bolus) required verification of the physician’s order for product and volume, review of the resident’s care plan, and administration of the prescribed amount of feeding and water by gravity flow using a syringe without a plunger, followed by clamping the tube before detaching the syringe. The resident had a physician’s order for Jevity 1.5 Cal, 300 ml bolus feedings every six hours. During observation, an LPN stated the resident received 600 ml of feeding and proceeded to use a syringe with a plunger to push 600 ml of Jevity 1.5 Cal into the resident’s gastrostomy tube, rather than allowing it to flow by gravity. Between drawing up each syringe of feeding, the LPN attempted to hold the gastrostomy tube with one hand, then laid the unclamped tube on the resident’s lap, causing feeding to leak out onto the resident. The LPN later confirmed that the physician’s order was for 300 ml, not 600 ml, and acknowledged that the tubing had been left unclamped during administration, resulting in leakage. The DON confirmed that physician orders should be followed for enteral feeding volume and that bolus feedings should be administered by gravity flow.
Failure to Properly Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The deficiency involves the facility’s failure to properly offer and administer pneumococcal vaccinations to two residents reviewed for immunizations. One resident had a Minimum Data Set (MDS) indicating moderately impaired thought processes and stated she did not remember being asked about the pneumonia vaccine at admission, but expressed that she would like to receive it if offered. Her family member and POA, who was present at admission, recalled the facility offering influenza and COVID-19 vaccines but not the pneumonia vaccine, and also stated it would be beneficial for her to receive the pneumonia vaccine. The resident’s Authorization and Release for Vaccinations form was marked as a refusal to sign but was undated. Another resident, whose MDS documented intact thought processes, reported not recalling that the pneumonia vaccine was offered at admission. She stated that the facility had offered influenza and COVID-19 vaccines during the current year but not the pneumonia vaccine, and that she would like to receive the pneumonia vaccine if available. The LPN Admissions Coordinator stated that she educates residents and families about the vaccine program at admission and reported that the first resident declined the pneumonia vaccine on a specific date, acknowledging that the refusal form should have been dated. The DON stated that simply asking residents on admission whether they want the pneumonia vaccine is not sufficient. The facility’s written Pneumococcal Vaccine Program policy requires staff to follow a protocol to determine eligibility upon admission, discuss recommendations with the physician when needed, and document education and refusals in the medical record, including when immunization is refused.
Widespread Cockroach Infestation in Food Service Areas
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in its food service areas, resulting in a significant German cockroach infestation. Observations revealed copious amounts of living and dead cockroaches in the staff lounge, which shares a wall with the kitchen and steam table food service line. The infestation extended to the refrigerator in the staff lounge, where cockroaches were found crawling through broken seals and present on shelves and drawers. The steam table food service line itself had numerous cockroaches in drawers and cabinets containing serving utensils, with live insects observed crawling onto the salad bar serving counter. Staff interviews confirmed that the cockroach problem had been ongoing and that pest control measures had not been effective. Dietary staff were observed using utensils stored in infested drawers to plate resident meals, and the Director of Nursing confirmed the presence of cockroaches in these areas during active meal service. Pest control invoices documented a high severity level of German cockroaches in the kitchen and recommended improved sanitation practices, which had not been adequately implemented. Facility policies required all food storage, preparation, and distribution areas to be kept clean and free of infection sources, and for an effective pest control program to be maintained, but these standards were not met. The deficiency had the potential to affect all 95 residents residing in the facility.
Unlicensed Staff Administered Medications
Penalty
Summary
A Certified Nursing Assistant (CNA), who was also a student in a Licensed Practical Nurse (LPN) program but not yet licensed, administered medications to several residents. The CNA stated that on one occasion, an LPN asked for assistance in handing out medications to residents who were waiting in the hallway. The CNA did not prepare the medications but distributed them to four or five residents as directed by the LPN, following instructions on whether to give the medications whole or in applesauce. The CNA could not recall the specific residents involved or the exact date of the incident, which occurred several months prior to the interview. Record review confirmed that the CNA was only eligible to work in that capacity and that the facility's job description for CNAs did not include medication administration. The facility's policy specified that only the Director of Nursing, licensed nursing personnel, and qualified medication aides are responsible for administering medications. The Director of Nursing confirmed that CNAs are not permitted to administer medications and was unaware that this incident had occurred. The facility had 95 residents at the time of the survey.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy and procedure, resulting in the presence of cockroaches in the kitchen, adjacent meal serving/steamtable area, and resident rooms. Observations included remnants and carcasses of cockroaches on glue boards and counters in the kitchen and serving areas. Staff interviews confirmed ongoing awareness of cockroach activity in these areas, with both maintenance and dietary staff acknowledging the presence of live and dead cockroaches. Invoices from the pest control company documented recurring cockroach issues in the kitchen and public areas over several months. A resident reported a direct encounter with a cockroach in their room, describing an incident where a cockroach was found crawling on their leg and subsequently retreated under the heating/AC unit. The Maintenance Director stated that pest control companies had sprayed affected areas, and that additional spraying was performed by facility staff, but no records were kept regarding the dates, times, or chemicals used. Surveyors also personally observed live cockroaches in common areas adjacent to the kitchen and serving areas. The facility's CMS Matrix 802 form documented that 95 residents resided in the facility at the time of the survey.
Failure to Provide and Document Showers for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, as documented by a Brief Interview of Mental Status score of 9/15, did not receive scheduled showers as required by facility policy. The resident required substantial to maximal assistance for personal hygiene and was scheduled to receive showers twice weekly. Review of the resident's shower documentation for the month revealed no entries indicating that showers were provided, nor any documentation of refusals or alternative hygiene measures such as bed baths. Interviews with staff confirmed that the resident had not received showers for an extended period, and that required documentation was missing. The resident herself could not recall her last shower and expressed a desire to be clean, while a family member reported persistent odors and raised concerns to staff without resolution. The Director of Nursing acknowledged the lack of documentation and stated that without completed records, there was no way to know if showers were missed or refused. The facility's policy, revised in August 2002, requires showers to promote cleanliness and observe skin condition, but this was not followed for the resident in question. The absence of documentation and follow-up resulted in the resident not receiving appropriate hygiene care, as confirmed by staff, the resident, and her family member.
Failure to Maintain Timely Supply of Controlled Substance Medication
Penalty
Summary
A deficiency occurred when the facility failed to maintain a timely supply of a Schedule IV controlled substance, Lunesta (eszopiclone), for a resident diagnosed with schizoaffective disorder, major depressive disorder with psychotic symptoms, generalized anxiety disorder, auditory hallucinations, and insomnia. The resident had a physician's order for Lunesta 2 mg to be administered at bedtime, but documentation showed that the medication supply was depleted and not replenished in a timely manner. The facility's records indicated that after the last dose was sent with the resident on a home visit, there were no further deliveries of Lunesta until a new prescription for an increased dose was received and filled several days later. During the period when Lunesta was unavailable, administration and nursing notes documented that staff were waiting on a signed prescription from the psychiatric provider, which is required for controlled substances. Multiple attempts were made by nursing staff to contact the psychiatric provider for the necessary prescription, but there was a delay in response. The medical director was notified of the situation, and an alternative medication, melatonin, was ordered to be given as needed for insomnia until the Lunesta prescription could be filled. The resident was aware of the missed doses and expressed concern about the interruption in receiving the prescribed medication, stating that the alternative medication did not work as well as Lunesta. Staff interviews confirmed that the delay was due to the psychiatric provider's failure to provide a signed prescription, despite repeated requests from the facility. The documentation shows that the resident went several days without the prescribed controlled substance due to this delay.
Failure to Administer PRN Pain Medication at Ordered Intervals
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident who was admitted with diagnoses including a right femur fracture, chronic ulcers on both lower legs, and gait abnormalities. The resident had a physician's order for Hydromorphone HCl 4 mg to be given orally every six hours as needed for pain. Record review revealed that the medication was administered at intervals shorter than the prescribed six hours on multiple occasions, with some doses given as little as 30 minutes apart. This deviation from the physician's order was confirmed by both the Director of Nursing and the Corporate Clinical Education staff upon review of the controlled drug records.
Failure to Document PRN Controlled Medication Administration on MAR
Penalty
Summary
The facility failed to document the administration of medication on the Medication Administration Record (MAR) for one resident reviewed for medication administration. According to the facility's policy, each medication or treatment administered must be promptly documented in the medication record after administration to validate that residents are receiving drugs and biologicals as ordered by the physician. In this case, a resident with diagnoses including a right femur fracture, chronic ulcers on both lower legs, and gait abnormalities was admitted and had a physician's order for Hydromorphone HCl Oral Tablet 4 MG to be given every six hours as needed for pain. Record review showed that the Controlled Drug Receipt/Record/Disposition form documented multiple administrations of Hydromorphone to the resident on various dates and times. Nursing staff confirmed that signing the controlled drug form indicated the medication was administered and that it should also be documented on the MAR. However, review of the MAR for the relevant month revealed that these administrations were not recorded as required, despite confirmation from nursing staff and facility leadership that the medication had been given according to the controlled drug records.
Failure to Complete and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to complete a physician-ordered wound treatment for one resident with chronic ulcers and a history of a right femur fracture. The resident's care plan required wound dressing changes to both knees twice daily, as ordered by the physician. On the day of the survey, the resident reported that the dressing changes had not been completed as scheduled, and the dressings present were dated from the previous day. Observation confirmed that both knee dressings were overly saturated with serosanguinous drainage, which had soaked through to the pillowcases and towels placed under the knees, as well as onto the bed. The resident stated that this was a common occurrence and that the dressing changes were not consistently performed twice daily as ordered. Record review showed that the Treatment Administration Record was signed off as if the wound dressing change had been completed that morning, despite the treatment not having been performed at that time. The physician's order specified the application of Gentamicin Sulfate Cream to the left knee twice daily at specific times. Nursing staff confirmed that the dressings were overdue and that the documentation did not accurately reflect the care provided. The facility's policy required prompt documentation of treatments after administration to validate that residents receive care as ordered, which was not followed in this instance.
Failure to Provide Supervision Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents with known fall risks. One resident, who had diagnoses including muscle weakness, lack of coordination, and repeated falls, experienced an unwitnessed fall in the shower after being left unattended by a CNA. The resident reported slipping while trying to get dressed after the shower, and the Assistant Director of Nursing confirmed that the CNA should not have left the resident alone. This resident had a history of falls, including incidents related to not locking walker brakes and a seizure, but the specific deficiency cited was the lack of supervision during the shower, which resulted in a fall. Another resident, with diagnoses of unspecified dementia, psychotic and mood disturbances, and a consistently high fall risk, required supervision while smoking according to assessments and care plans. Despite this, the resident was left unsupervised on the smoking patio, where she fell after her walker became caught on uneven pavement. The fall was witnessed by another resident, who reported that no staff were present at the time. The Assistant Director of Nursing confirmed that this resident was not independent with smoking and required staff supervision, which was not provided at the time of the fall.
Failure to Secure Indwelling Catheter and Prevent Leakage
Penalty
Summary
A deficiency occurred when staff failed to maintain a urinary indwelling catheter in a secure manner for a resident with a diagnosis of obstructive and reflux uropathy. The resident's care plan indicated the presence of an indwelling catheter and a risk for urinary tract infection, with a goal to remain free from catheter-related trauma. During observation, it was noted that the resident did not have a security leg strap or any adhesive tape to secure the catheter, as required by facility policy. The catheter tubing and drainage bag were also not dated, and the resident's linen and bed were found to be wet due to urine leakage from the catheter. The resident reported ongoing pain at the catheter insertion site, describing sensations of the catheter pulling and requests for the catheter to be secured, which had not been addressed. The resident also stated that the catheter had not been changed monthly as ordered, and that frequent leakage resulted in daily pad changes by CNAs. The CNA confirmed the absence of a leg strap and the need to notify the nurse about the resident's pain. Facility policy required the use of adhesive tape or a leg band to secure the catheter, but this was not implemented, leading to the resident's discomfort and repeated episodes of urine leakage.
Failure to Maintain Odor-Free Resident Room Due to Accumulated Soiled Laundry
Penalty
Summary
The facility failed to maintain a resident room free of odors from urine-soaked clothing, affecting one resident with severe cognitive impairment and substantial assistance needs for toileting hygiene. Observations and interviews revealed that soiled clothing was left to accumulate on the resident's floor, resulting in a strong odor. Staff acknowledged that laundry is supposed to be picked up at least every shift and returned the same day, but admitted that this was not always achieved. A CNA confirmed that the resident often removes her own clothes and leaves them on the floor, and that staff are responsible for picking up soiled laundry and assisting with toileting, but in this case, a large amount of urine-soaked clothing had accumulated over several days. A family member reported finding several large garbage bags of urine-soaked clothes in the resident's room and noted that the resident's recliner was also saturated due to lack of protective pads. The facility's policy requires maintaining a clean, odor-free, and comfortable environment, but this was not upheld in the resident's room. The deficiency was identified through observation, staff and family interviews, and review of facility policy.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care to a resident who was dependent on staff for hygiene due to paraplegia, lack of coordination, and weakness. The resident was cognitively intact and required assistance with personal care, including toileting and bed mobility. On the early morning in question, the resident requested assistance from a CNA to be cleaned after an episode of incontinence. The CNA stated they would return but did not, and the resident reported waiting approximately 45 minutes while hearing the CNA in another room. The resident alerted multiple staff members, including another CNA and a registered nurse, but was not cleaned until the day shift arrived. Interviews with staff confirmed that the resident's call light was answered, but the aides prioritized getting other residents up for the day instead of providing the requested incontinence care. The CNAs and RN acknowledged the resident's request but did not provide care at that time, with the RN stating they were in the middle of a medication pass and would find someone to help. Documentation did not show any incontinence care provided to the resident on the date in question. The facility's policy requires prompt response to call lights and resident needs, which was not followed in this instance.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency are not provided in the report.
Failure to Ensure Resident Dignity During Care and Discharge
Penalty
Summary
The facility failed to ensure the dignity of two residents as evidenced by staff actions and omissions. In the first instance, a cognitively intact resident with multiple medical diagnoses, including heart failure and diabetes, was reportedly treated roughly by the facility administrator, who took silverware from the resident's hand while eating and removed the resident from the dining area. The resident's personal belongings were packed without explanation, and the resident was transported away from the facility without being informed of the reason, causing confusion and distress. Staff reported that the resident's belongings were left on the ground outside, and the resident repeatedly asked why she was being removed, indicating a lack of communication and respect for her dignity. In the second instance, another resident who required assistance to prepare for dialysis activated the call light early in the morning but did not receive timely help. Two CNAs arrived shortly before the resident's scheduled transportation and hurriedly prepared him, resulting in a washcloth being left inside his incontinence brief. The resident became aware of an odor after dialysis, which was confirmed by both the dialysis nurse and the transportation driver, leading to feelings of humiliation. Upon return to the facility, staff discovered the washcloth during care, and the resident was visibly upset and requested to be left alone. These events demonstrate failures in providing dignified and attentive care to the residents involved.
Failure to Prevent Verbal Abuse Between Roommates
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving two residents sharing a room. One resident, who had a history of alcohol abuse, cognitive impairment, and multiple medical diagnoses, was moved into a room with another resident who had moderate cognitive impairment and required significant assistance with activities of daily living. Shortly after the room change, both residents engaged in a verbal altercation, during which one resident threatened the other with bodily harm. This exchange was witnessed by a housekeeper, who confirmed hearing the threat and the yelling from the nurse's station. The facility's Abuse Prevention Program policy requires staff to identify residents with increased vulnerability to abuse and to implement care planning strategies to reduce the risk of abuse, neglect, or mistreatment. Despite these requirements, the care planning and monitoring processes did not prevent the verbal abuse incident. The resident who was threatened reported that his belongings were moved without his knowledge and that he was subjected to yelling and threats of bodily injury by his roommate. Staff intervention occurred only after the altercation, when the threatened resident was moved to another room.
Failure to Serve Hot and Palatable Food to Residents
Penalty
Summary
The facility failed to ensure that hot food was served to three residents out of three reviewed for dietary services. Observations conducted over several days revealed that meal trays were delivered to the hallway by kitchen staff, but nursing staff delayed passing the trays to residents for periods ranging from 11 to 18 minutes. The trays contained both hot and cold food items, but there was no hot plate under the ceramic plates to maintain food temperature. Multiple residents reported that their food was consistently cold, and some stated they had informed staff about this issue previously. One resident mentioned requesting staff to reheat food in a microwave, while another reported not eating meals due to the food being cold and unappetizing. Resident Council meeting minutes from two separate months documented ongoing complaints from residents about cold food. The residents involved had varying cognitive statuses, with two being cognitively intact and one having moderate cognitive impairment. The deficiency was identified through interviews, record reviews, and direct observations, all of which consistently indicated that the facility did not maintain food at a safe and appetizing temperature during meal service.
Failure to Provide Sufficient Linens for Resident Care
Penalty
Summary
The facility failed to provide sufficient linens to ensure a safe and sanitary environment for all 98 residents. On the day of the survey, only one out of three washing machines was operational, and two out of four dryers were working. Observations revealed that only about three dozen each of hand towels and washcloths were available in storage areas. Staff interviews confirmed ongoing shortages, with housekeeping and laundry aides reporting frequent linen shortages, especially on weekends, and difficulty keeping up with laundry demands due to understaffing. The Director of Nursing also acknowledged shortages of both linens and housekeeping staff, sometimes requiring staff to be pulled from other duties to complete laundry tasks. Resident interviews during a council meeting revealed that multiple residents had not received showers in the past week, with staff attributing this to a lack of linens and laundry staffing. Residents reported that grievances about this issue had been filed after every monthly council meeting, and that scheduled showers were not being provided as required. Facility policy requires specific linens for bathing, but the lack of available linens prevented adherence to this policy.
Failure to Provide Required Showers and ADL Assistance Due to Linen and Staffing Shortages
Penalty
Summary
The facility failed to provide showers and adequate assistance with activities of daily living (ADLs) for five residents who were unable to perform these tasks independently. During a Resident Council meeting, multiple residents reported not having received showers in the past week, despite facility policy requiring showers twice weekly. Observations confirmed that these residents had visible signs of poor hygiene, including food on their clothing, oily hair, and dirt under their nails. Medical records corroborated that the last documented showers for these residents were well beyond the required frequency, with some not having received a shower for up to two weeks. Interviews with staff revealed that a shortage of linens and housekeeping staff contributed to the failure to provide showers. Certified Nursing Assistants (CNAs) reported running out of linens, particularly on weekends, and the Director of Nursing confirmed that staff shortages led to CNAs being unable to locate necessary supplies. Additionally, it was noted that towels and linens were sometimes stored in residents' drawers, further complicating access. Despite grievances being filed by residents after each monthly council meeting, there was no reported improvement in the provision of showers or ADL assistance.
Failure to Accurately Account for and Document Controlled Medications
Penalty
Summary
The facility failed to accurately account for controlled medications and document shift-to-shift controlled medication counts for all seven residents reviewed for controlled medications. Facility policy requires that controlled medications be counted at the end of each shift by both the outgoing and incoming nurse, with documentation and reporting of discrepancies to the Director of Nursing (DON). However, observations revealed that controlled medication binders for multiple medication carts were missing required Controlled Substance Shift Change Count Sheets, and where forms were present, they often lacked two nurse signatures or had missing entries for specific dates. The DON confirmed that not all required forms could be located for the relevant months and that the process was not being followed as outlined in facility policy. Further review of medication administration records (MARs) and controlled drug receipt/record/disposition forms showed discrepancies in medication administration documentation. For example, one resident received Lorazepam without an active order in the electronic medical record, and doses were administered and signed out on controlled drug records but not on the MAR. Staff interviews revealed that medications were sometimes given based on verbal reports or hospice instructions without verifying active orders in the electronic record, and doses were not always documented on the MAR as required. In another case, a resident's Norco administration was not recorded on the MAR, despite being signed out on the controlled drug form, with staff citing power outages as a reason for not completing documentation. These findings demonstrate that the facility did not consistently follow its own policies for controlled medication management, including shift-to-shift counts, dual nurse verification, and accurate documentation of medication administration. The discrepancies between controlled drug records and MARs, as well as missing or incomplete count sheets, were confirmed by staff and the DON during the survey.
Failure to Administer and Reorder Medications Timely, Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered timely and as ordered, and did not consistently reorder medications to prevent running out, resulting in significant medication errors for four residents. For one resident, a change in Tramadol order from PRN to scheduled dosing was not properly managed, leading to missed doses due to delays in obtaining a signed prescription and confusion over whether the medication should be administered as needed or on a schedule. Documentation showed that the resident was without Tramadol for multiple scheduled doses, and staff and pharmacy communications revealed delays in reordering and confusion about medication supply responsibilities. Another resident experienced a lapse in receiving Norco due to the facility running out of the medication and delays in sending a signed prescription to the pharmacy. This resident also had multiple instances where other medications, including insulin and antihypertensives, were administered significantly later than scheduled, with no documentation of physician notification regarding these delays. Nursing notes confirmed the lack of timely communication with the physician and delays in medication administration. A third resident did not receive scheduled doses of Amlodipine and Metoprolol on several occasions, with the nurse withholding the medications based on blood pressure readings despite the absence of physician-ordered parameters for withholding. There was no documentation of physician notification for these withheld doses. Additionally, another resident reported repeated delays in receiving evening medications, with audit reports confirming multiple instances of late administration. Staff interviews attributed these delays to workload and staffing issues, and the DON confirmed the expectation for timely administration and documentation, which was not met in these cases.
Failure to Properly Store and Destroy Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly stored and destroyed according to policy for two residents. In one instance, a resident's Morphine Sulfate was found stored in the bottom drawer of a medication cart, which is not a locked compartment designated for controlled substances. The medication was supposed to be kept in a locked controlled medication compartment, but was instead located among inhalers. The controlled drug record indicated that only one dose had been signed out, and staff interviews confirmed that the medication was misplaced and not secured as required. Additionally, the facility's controlled substance shift change count sheets were incomplete, with missing entries for the relevant period, and the Director of Nursing confirmed that the required documentation was not fully available. In another case, a resident's Norco prescription had been discontinued, but the medication card with 19 tablets remained in the locked compartment of the medication cart. The order for Norco had been discontinued several days prior, yet the medication was not removed or destroyed as per facility policy. The Director of Nursing verified that the medication should have been pulled and destroyed after discontinuation, but this was not done, resulting in the continued presence of discontinued controlled medication in the facility.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders and manufacturer recommendations for five residents, resulting in a medication error rate of 13.51 percent. For one resident, Flonase was not administered because it was not available in the medication cart, despite being a stock drug. Another resident did not receive their Hydrocodone-Acetaminophen due to the pharmacy's delayed delivery, which had occurred previously. Additionally, a resident was not instructed to rinse their mouth after using Trolley Lepta, as required by the physician's order. Further errors included administering the incorrect dosage of Tylenol to a resident, where 500 mg was given instead of the prescribed 325 mg. Another resident did not receive their Budesonide Formoterol Fumarate as ordered, even though the medication was available on the cart. These incidents highlight a failure to adhere to the facility's Medication Administration Policy, which mandates that drugs be administered in accordance with licensed medical practitioners' orders.
Resident Intimidated by RN's Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Registered Nurse (RN), which resulted in the resident experiencing mental anguish, fear, and anxiety. The incident involved a resident who is cognitively intact and has paraplegia. The resident reported that the RN entered his room aggressively after mishearing a conversation about a 'stink' in the hallway as a threat to call the 'state.' The RN reportedly yelled at the resident, causing him to feel intimidated and scared, especially given his inability to physically defend himself due to his condition. The resident immediately reported the incident to the Administrator-In-Training, expressing feelings of being threatened and abused. However, the administrator dismissed the resident's concerns, attributing them to the resident's history of being 'ridiculous.' A Certified Nursing Assistant (CNA) who witnessed the incident corroborated the resident's account, describing the RN's behavior as aggressive and threatening. Despite the resident's expressed fear and discomfort, the RN continued to work that night and later returned to the resident's room to offer an apology, which the resident rejected. The facility's inaction in addressing the resident's concerns and the RN's behavior contributed to the resident's ongoing distress and lack of safety in his environment.
Failure to Investigate Abuse Allegation and Protect Residents
Penalty
Summary
The facility failed to implement its Abuse Policy to thoroughly investigate an allegation of abuse and protect residents from the alleged perpetrator. A resident reported feeling threatened and verbally abused by a registered nurse (RN) and immediately informed the Administrator-In-Training. Despite the report, the RN continued to work that night and was not suspended. The Administrator-In-Training only spoke to the resident and the RN, without conducting a full investigation or removing the RN from duty. The RN continued to care for all residents in the 300-hallway, including the resident who made the allegation, without any suspension or further inquiry. The facility's records, including the Abuse Investigations and the resident's Electronic Medical Record, did not show any evidence of an investigation into the abuse allegations. The facility's Abuse Prevention Program policy requires immediate protection of residents and prompt investigation of all reports of abuse, which was not followed in this case.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Policy by not immediately reporting an allegation of abuse to the State Agency. A resident reported feeling threatened and verbally abused by a registered nurse to the Administrator-In-Training. Despite receiving this report, the Administrator-In-Training did not report the allegation to the state agency as required by the facility's Abuse Prevention Program policy. The policy mandates that any allegation of abuse be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation. The facility's records did not include evidence of the abuse allegation being reported to the State Agency, indicating a failure to adhere to the established policy.
Facility Fails to Maintain Functional and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain the shower rooms in a homelike and functional condition, affecting all 102 residents. On multiple occasions, surveyors observed the shower rooms on the 200 and 300 halls in a state of disarray, with construction debris, tools, and equipment scattered throughout. The 200 hall shower room had hardened cement tile mastic, a steel mixing blade, and a pile of tiles from demolition. The 300 hall shower room was being used as a storage area, with various items such as recliners, mechanical lifts, and housekeeping carts cluttering the space. Both shower rooms had been shut down for safety reasons, and the facility had not completed the necessary repairs. The Maintenance Director, V12, stated that the repair work had been ongoing for six months, but the individual responsible for the work had not returned to finish the job. The Administrator, V1, confirmed that the shower rooms on the 200 and 300 halls had been non-functional for approximately two months due to water damage and loose tiles. Despite attempts to obtain estimates for repairs, no progress had been made, and the facility's maintenance staff was unable to complete the work due to other responsibilities. Residents expressed dissatisfaction with the condition of the shower rooms, noting the presence of mold, insects, and construction debris. Several residents reported having to use shower rooms on other halls, which were also in poor condition. The 100 and 400 hall shower rooms had issues such as blackened areas resembling mold, non-functional valve handles, and doors that did not close properly. Residents expressed frustration with the ongoing construction and the lack of progress in completing the repairs.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to maintain the dishwasher water temperatures at the required level to sanitize dishware, potentially affecting all 102 residents. During observations, the dishwasher's final rinse temperatures were recorded at 156 F, 161 F, and 163 F, which are below the required 180 F for proper sanitation. The Dietary Manager, V22, confirmed the required temperatures and acknowledged the issue, suggesting the use of disposable plates and utensils as a temporary measure. The Maintenance Director, V12, had contacted a service company for repairs, but they were unavailable until the following day. The Administrator, V1, was unaware of the issue until informed during the survey and recognized the need for better communication among staff to address such problems promptly. Despite the availability of a 3-compartment sink for manual dishwashing, the dietary staff were reluctant to use it due to the time it required. The facility's contract with a specific service company further complicated the repair process, as another technician could not service the dishwasher without breaching the contract.
Facility Lacks Qualified Social Worker for 154-Bed Capacity
Penalty
Summary
The facility failed to provide the services of a qualified Social Worker for their facility with a bed capacity of 154, affecting all 102 residents residing in the facility. The Administrator, identified as V1, confirmed that the facility does not have a Social Worker with a degree and has not had one for an undetermined period. The former Social Services Director, V31, who does not possess a bachelor's degree in Social Work or a Human Services Field, was moved to the position of Business Office Manager. V31 had minimal supervision in the role of Social Services Director, receiving only two hours of consultation on one occasion. The facility's staff roster does not list anyone in the Social Services position, confirming the vacancy.
Pest Control Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain an effective pest control program, which was evident through the presence of pests in the kitchen area. During an observation, the Maintenance Director noticed a live cockroach on a trash can next to the dishwasher and numerous small flying insects, commonly referred to as sewer flies or fruit flies, around the floor drains and dishwasher area. The floor in the dishwasher area was saturated with water due to the dishwasher spraying out water when the cycle started, and a significant amount of water was observed coming out from under the dishwasher door. Additionally, a two-compartment stainless steel sink adjacent to the food preparation counters was leaking sewage water onto the floor. The Dietary Manager acknowledged awareness of the flies, particularly around the floor drains and dishwasher drain, and mentioned that the kitchen staff attempted to keep the floor dry and used chemicals to eliminate the flies. A maintenance work order had been submitted for the leaking sink drains. Resident complaints about fruit flies were documented in the facility's Resident Council Meeting Minutes from February 2024, indicating an ongoing issue.
Non-Functional Door Alarms and Monitoring Systems
Penalty
Summary
The facility failed to maintain its door alarms and computer-based door monitoring systems in functional condition, which could potentially affect all 102 residents. The Maintenance Director, V12, acknowledged that the system was not functioning to emit a sound when a door was opened, and the monitor screens at various nurse stations were either black or not displaying the facility floor map. This required staff to visually monitor the screens to know if a door was opened, which was not feasible given the system's current state. Additionally, several doors, including those leading to courtyards and a loading dock, did not have functional audible alarms, and some could be opened with a simple push. The electronic bracelet monitoring alarms were functional, but not all residents used them. The Administrator, V1, expressed concern over the non-functional door alarms and acknowledged that the Maintenance Director and Assistant were supposed to check the alarms daily. However, there was a lack of communication and action to address the issues promptly. During the survey, it was observed that staff were not always present in areas where residents could potentially exit the facility unsupervised, such as the activity room and during scheduled smoking times. The staff also did not respond to audible announcements of doors being ajar, as they were unaware of which doors were open due to the non-functional screens.
Inaccurate Smoking Status Assessment and Documentation
Penalty
Summary
The facility failed to accurately assess and document the smoking status of three residents, leading to discrepancies in their Minimum Data Sets (MDS) and care plans. Specifically, the smoking schedule listed five residents as current smokers, but the MDS for three of these residents inaccurately documented them as non-smokers. Resident 11's MDS did not reflect her current tobacco use, and her care plan lacked a focus area for smoking, despite her smoking assessment indicating she requires assistance to light cigarettes. Resident 12's MDS also inaccurately documented no tobacco use, and his smoking assessment was incomplete, though it noted he does not light his own cigarette safely. Resident 13's MDS incorrectly documented her as a non-smoker, although she had resumed smoking after admission. The Infection Preventionist/Wound Nurse confirmed these discrepancies and acknowledged that Resident 13 should have been reassessed when she resumed smoking.
Failure to Timely Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to timely assess residents for the risk of developing pressure ulcers and to complete pressure ulcer treatments according to physician orders. This deficiency affected three residents who were reviewed for wound care. For one resident, the Braden Scale assessment was not updated, and multiple instances of missed documentation for pressure ulcer treatments on the sacrum, buttocks, and right heel were noted in both November and October. Another resident's treatment administration record showed missed documentation for pressure ulcer treatments on the sacrum and daily skin checks in October and September. Similarly, the third resident's treatment records indicated missed documentation for pressure ulcer treatments on the left outer ankle and sacrum in October and November. The facility's policy requires Braden Assessments to be conducted upon admission, weekly for the first month, then quarterly, and with any significant change in condition. However, the most recent Braden Scale assessments for the residents were not updated as per the policy. Additionally, the facility's policy on medication and treatment administration requires prompt documentation of each treatment administered, which was not adhered to, as evidenced by the missing documentation in the treatment administration records for the residents involved.
Lack of Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), which is a requirement for the operation of the facility. This deficiency affects all 109 residents residing in the facility. The Administrator confirmed that the facility has not had a full-time DON for six months. During the survey conducted from November 19 to November 22, 2024, there was no DON working in the facility. The CMS-802 Matrix form dated November 19, 2024, documents that 109 residents reside in the facility.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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