Franciscan Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Lemont, Illinois.
- Location
- 1270 Franciscan Drive, Lemont, Illinois 60439
- CMS Provider Number
- 146029
- Inspections on file
- 28
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Franciscan Village during CMS and state inspections, most recent first.
Multiple residents dependent on staff for transfers, including those with stroke, dementia, and mobility deficits, were not provided with required assistance or proper use of assistive devices during transfers. In one case, a nurse attempted a solo transfer of a resident needing two-person assistance, resulting in a fall and hip fracture. Other residents were transferred without gait belts or proper positioning, and required safety interventions such as non-skid wheelchair pads were not used, despite documented high fall risk and prior incidents.
Surveyors identified multiple unsanitary practices affecting all residents receiving facility-prepared meals, including use of a food processor with visible food residue to prepare mechanical soft foods, dirty and possibly rusted shelving storing pots, pans, and food-service supplies, and a deep fryer and surrounding cooking areas with accumulated food debris and spills that were not promptly cleaned. Ceiling tiles above food prep areas were covered with blackish substance and dust, and cases of juice were stored directly on the cooler floor rather than elevated. Dishes for one floor were washed in an alternate dish room where a high-temp dish machine failed to reach required rinse temperatures, test strips and a digital temperature monitor were unavailable, and temperature logs were completed only for one meal per day, contrary to facility policy requiring proper cleaning, storage, and dish machine monitoring.
Surveyors found that controlled substances were not maintained in fully sealed original packaging, as required by facility policy and DEA-related handling standards. During medication room and cart observations on multiple floors with nursing staff present, several unit-dose packages of Lorazepam, Triazolam, Hydrocodone/APAP, Tramadol, and Oxycodone were discovered with broken blisters or capsules that had been taped over instead of remaining intact. The DON confirmed that staff are expected to keep all controlled medications in their original, completely sealed packaging to ensure full accountability of each tablet or capsule, consistent with the facility’s written policies on medication storage and controlled substance management.
Surveyors found that staff did not provide fortified foods as indicated on meal tickets for six residents with documented nutritional risk, weight loss history, or inconsistent intake. The RD entered fortified food recommendations into the kitchen system so they appeared on meal tickets, and care plans for these residents included interventions to provide fortified foods. During observed meal services, residents whose tickets called for fortified pudding or a magic cup did not receive these items, despite the dining services leadership stating that fortified pudding was to be prepared and plated by servers whenever listed on the meal ticket.
Staff failed to follow the facility’s menu and portion control guidelines when serving the main entrée to residents on mechanical soft diets. On an observed meal service, a server used a #12 (3 oz) scoop instead of the menu-specified #8 (4 oz) scoop to portion ground chopped beef steak with gravy for four residents receiving dental soft diets. The facility’s color-coded scoop chart showed that the #8 scoop equaled 4 oz, and the registered dietitian confirmed that the scoop size indicated on the menu is used to ensure residents receive the planned calories and nutrition.
Surveyors found that multiple residents on mechanical soft (dental soft) diets were served foods inconsistent with their diet orders and facility policy. During an observed meal, several residents who had selected soft, chopped green beans on their meal tickets were instead served corn, and another resident on a mechanical soft diet received chopped fruit containing raw pineapple chunks. The RD later confirmed that mechanical soft diets should include only chopped canned fruits and soft, cooked vegetables, and dining services leadership acknowledged that pineapple chunks and the substituted vegetables were not appropriate for this diet level.
Two residents did not receive needed ADL assistance with feeding and incontinence care as outlined in their care plans and physician orders. One cognitively intact resident with Parkinson’s disease and dysphagia, ordered for 1:1 feeding due to self-care deficits and inadequate oral intake, was repeatedly given meal trays in the dining room and in bed without staff feeding assistance or encouragement, resulting in only partial meal consumption and spilled beverages, while dietary staff relied on nursing to communicate 1:1 feed orders that did not appear on diet tickets. Another resident with dementia and bowel incontinence was observed in bed with a strong bowel odor and flies present after several hours without personal care, despite a care plan requiring checks every two hours; a CNA described checking such residents every 2.5–3 hours, whereas the DON stated residents should be checked every two hours and as needed. Grievance logs and resident council reports documented multiple concerns about ADLs, and facility policies required provision of appropriate ADL and incontinence services for residents unable to perform these tasks independently.
A resident with dementia and a recent left femur fracture, admitted for post-surgical care and rehab, experienced significant pain during incontinence care and when movement was attempted. Despite active orders for scheduled and PRN acetaminophen and hydrocodone-acetaminophen, staff did not adequately assess or pre-medicate for anticipated pain before providing care. A CNA reported the resident screamed and yelled when touched and that the nurse initially stated she did not know if pain medications were ordered, while the nurse later indicated she was waiting until care was completed to administer analgesics. The resident declined repositioning for eating due to pain, and the DON and facility policies indicated that residents in significant pain should be assessed, medicated prior to care when possible, and care delayed or re-approached if they cannot tolerate it, which did not occur in this situation.
Surveyors observed a nurse crush and administer an ER Metoprolol tablet to a resident, contrary to the facility’s medication crushing guidelines, and fail to administer an ordered dose of Polyethylene Glycol 3350 (Miralax) listed on the MAR. During interview, the nurse stated that the medications given were the only morning medications for the resident, despite the active order for Miralax. Across 28 medication opportunities, these two errors produced a 7.14% medication error rate, exceeding the 5% standard.
Staff failed to follow standard infection control practices for hand hygiene and glove use during ADL care. In multiple instances, CNAs provided toileting and incontinence care, including peri care after voiding and bowel movements, and applied barrier cream and clean briefs while continuing to wear the same gloves throughout the care. In another case, a CNA assisted a resident with a catheter and dirty-soled shoes, touching the catheter bag, clothing, shoes, and surrounding surfaces while moving between dirty and clean tasks without changing gloves. The facility’s policy required hand hygiene after contact with body fluids, intact skin, and nearby objects, and required changing gloves when moving from contaminated to clean body sites.
A resident experienced a 12.47% weight loss over 90 days due to the facility's failure to obtain monthly weights and recognize significant weight loss. The resident expressed dissatisfaction with the facility's food, and despite orders for monthly weights and a mechanical soft diet, weights were inconsistently documented. Communication issues and staff changes contributed to the oversight, with the facility's policy on weight management not being followed.
The facility failed to manage food storage and expiration, affecting all 98 residents. Expired food items were found in dry storage, and the freezer contained unlabeled cheese. Ice buildup was observed around the walk-in freezer, with maintenance issues unaddressed despite a work order. The facility's policy on food storage and expiration was not followed.
The facility failed to provide adequate assistance with ADLs for residents dependent on staff for personal hygiene and grooming. Observations revealed residents with long, unkempt fingernails and female residents with facial hair, despite their care plans indicating a need for substantial assistance. Staff interviews confirmed the expectation for grooming assistance, yet the facility did not adhere to its policy of maintaining residents' personal hygiene.
The facility failed to maintain proper infection control practices, including hand hygiene and PPE use, during care activities for several residents. A CNA did not clean hands between tasks during meal service, and a wound care nurse and CNA did not follow hand hygiene protocols during wound care. Additionally, Enhanced Barrier Precautions were not implemented for residents requiring them, as staff failed to wear gowns during high-contact care activities.
The facility failed to ensure call lights were within reach for three residents, each with significant medical conditions and cognitive impairments. Observations revealed that call lights were either out of reach or improperly placed, preventing residents from calling for help. Staff interviews confirmed that call lights should always be accessible, aligning with the facility's policy. However, this was not consistently practiced, posing a risk to resident safety.
The facility failed to invite two residents to their care plan meetings, as required by policy. Both residents reported not attending or being invited to such meetings since their admission. The facility's records lacked documentation of invitations or attendance, and the administrator acknowledged the requirement for resident involvement but could not provide evidence of compliance.
The facility failed to provide adequate activities for two residents, as required by their care plans. One resident reported not receiving in-room activities or pop-in visits, while another expressed a desire for computer games, which were not provided. Documentation showed minimal activity entries, and staff confirmed that activities were not consistently offered to residents in their rooms, contrary to facility policy.
The facility failed to provide restorative nursing programs for residents with limited range of motion, affecting three residents. One resident with limited arm mobility and inwardly turned feet did not receive recommended exercises post-therapy. Another resident in a wheelchair reported inconsistent exercise assistance, despite having multiple diagnoses and functional limitations. A third resident with a dislocated shoulder expressed a need for exercises to prevent further decline. The Director of Nursing confirmed the absence of a restorative nurse and programs, contrary to facility policy.
A facility failed to implement fall prevention measures for a high-risk resident, as fall mats were not properly placed and the bed was not in the lowest position. Despite the resident's care plan indicating the need for bilateral floor mats, observations showed inconsistent application of these safety measures. Interviews with staff confirmed the standard practice, but it was not followed for this resident.
Failure to Ensure Safe Transfers and Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure safe transfer mobility and adequate supervision for residents dependent on staff for transfer assistance, resulting in multiple incidents. One resident with a history of stroke, left-sided weakness, and cognitive impairment was dependent on staff for all transfers. Despite care plan instructions requiring two-person assistance, a registered nurse attempted to transfer the resident alone, during which the resident lost balance and fell from the wheelchair, hitting her head and sustaining a left femoral neck fracture. Family members present at the time reported that the nurse did not respond to their warnings about the resident's inability to move her left leg, and the transfer was performed without proper positioning or assistance, leading to the fall. Another resident with dementia, generalized muscle weakness, and a history of repeated falls was assisted by a CNA during toileting without the use of a gait belt, despite care plan interventions specifying two-person assistance and gait belt use for transfers. This resident was identified as high risk for falls and had a recent history of multiple fall incidents, as well as a visible wound on her forehead from a previous fall. A third resident with vascular dementia and a history of fractures was transferred from a reclining wheelchair to bed using a mechanical lift by two CNAs. During the transfer, the resident was not properly positioned in the sling, with lower extremities unsupported, causing the resident to scream in pain as the sling slid. Additionally, another resident with spinal stenosis and dementia, also at high risk for falls, was transferred from bed to wheelchair using a gait belt but without a non-skid wheelchair pad as required by the care plan. The resident appeared afraid and hesitant during the transfer, and the facility's fall log indicated a history of multiple falls for this resident.
Unsanitary Food Preparation, Storage, and Dishwashing Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain sanitary conditions in the kitchen and dishwashing areas for all 97 residents who receive food prepared there. During an initial kitchen tour, surveyors observed a food processor lid with orange-colored debris on the inside; the cook reported this processor is used to prepare mechanically soft foods. Shelving under a prep area that stored foil, plastic wrap, pan liners, and sandwich bags had food particles, dust, and grime. The deep fryer contained oil with blackened substances and food remnants, and there were food debris and spills on the sides of the oven near the fryer and extensive food spills and debris under the stoves. The cook stated the fryer was last used several days earlier and is cleaned twice weekly, with the next cleaning not yet due. In the dish room, shelving on a free-standing rack holding inverted pots and pans had a brownish substance that appeared to be rust. In the walk-in cooler, surveyors observed cases of orange and apple juice stored directly on the floor under shelving; the executive chef explained these juices had been moved there temporarily from the walk-in freezer due to a fan motor issue. Later the same day, a cook was seen preparing mechanical soft chicken in the same food processor previously noted to have orange-colored residue on the lid. When questioned, the cook removed the rubber lining and stated the substance appeared to be remnants of pureed carrots and that the lid was old and needed replacement. Ceiling tiles above the pureed meal prep area and other meal prep counters had extensive blackish substance and dust bunnies. The director of dining services acknowledged seeing rust on the shelving and stated that the food processor should have been cleaned and sanitized before being used to prepare the mechanical soft chicken. On a subsequent visit, the deep fryer and surrounding areas still had food debris and spills, and the ceiling tiles above food prep areas continued to have extensive blackish substance and dust bunnies. The executive chef reported that dishes for the first floor were being washed in the assisted living dish room because the main dish room was under construction. When the dish machine was started, the wash gauge read 140°F and the rinse gauge 160°F, although the chef stated it was a high-temperature machine and the rinse should normally be 180°F. When asked about test strips to verify sanitation, the chef was unable to locate them and indicated they typically used a digital monitor that was not present. The assisted living dishwasher stated the digital monitor had not been available for two months, that he only completed dish machine logs for the dinner meal, and that no one else logged temperatures for other meals. The posted dish machine temperature log showed rinse temperatures between 155–175°F for most entries in July and August and was completed for only one meal per day. Facility policies required food contact surfaces to be cleaned and sanitized after every use, foods to be stored at least six inches off the floor, and high-temperature dish machines to reach minimum wash and rinse temperatures and be monitored and documented at each meal, which was not followed in these observations.
Improper Storage and Packaging of Controlled Substances
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of controlled substances when multiple medication packages were found broken and taped over rather than remaining fully sealed in their original packaging. During medication room and cart observations conducted on all three floors, surveyors, accompanied by nursing staff, observed that specific unit-dose packages of controlled medications for seven residents were compromised. These included Lorazepam 0.5 mg tablets for one resident at tablet number 18, another at tablet number 27, and a third at tablet number 16; Triazolam 0.25 mg tablets at tablet numbers 1 and 5 for another resident; Hydrocodone/APAP 5-325 mg at tablet number 20 for another resident; Tramadol 50 mg at tablet number 12 for another resident; and Oxycodone HCL 5 mg at capsule number 29 for another resident. In each instance, the packaging was described as broken and then taped over. The DON stated that staff are required to ensure controlled substances remain in their original packaging and are completely sealed to maintain complete accountability of each tablet or capsule. The facility’s March 2021 medication storage policy requires medications and biologicals to be stored safely, securely, and properly, following manufacturer or supplier recommendations. The controlled substance storage policy further specifies that medications classified by the DEA as controlled substances are subject to special handling, storage, disposal, and recordkeeping in accordance with federal, state, and other applicable laws and regulations. The observed practice of storing controlled substances in broken, taped-over packaging was inconsistent with these stated requirements.
Failure to Provide Ordered Fortified Foods to Residents at Nutritional Risk
Penalty
Summary
The facility failed to provide ordered fortified foods to six residents who had recommendations and care plan interventions for fortified foods to address nutritional risk, weight loss, or inconsistent intake. During meal service observations on the 2nd floor dining room, residents identified as R18 and R95 had meal tickets indicating "fortified pudding" but did not receive it, and R78’s meal ticket indicated "magic cup" but she did not receive it. During meal service observations on the 3rd floor dining room, residents identified as R35, R45, and R64 had meal tickets indicating "fortified pudding" but did not receive it. The Registered Dietitian (V17) stated that when she recommends fortified foods, she enters these recommendations into the kitchen platform so they appear on the facility meal tickets, and that fortified foods do not appear on the Physician Order Sheet but should be provided if they appear on the meal ticket. The Assistant Dining Service Director (V6) stated that the facility no longer has magic cup, that residents are to receive fortified pudding instead, and that servers are supposed to plate fortified pudding in bowls and place them on the tray with the rest of the meal. Despite this, the fortified items indicated on the meal tickets were not served to the identified residents. Care plans for all six residents documented nutritional concerns and included interventions to provide fortified foods: R18 and R95 were noted to be at increased nutritional risk or at risk for unintentional weight loss related to advanced age, impaired cognition, and variable intake; R35, R45, and R64 had histories of inadequate intake and weight loss; and R78 had inadequate intake related to early satiety with observed 50% meal consumption. The Registered Dietitian confirmed that she recommended fortified pudding or magic cup for these residents due to either past significant weight loss or inconsistent intake, and that if fortified foods appear on the meal ticket, the resident should receive them.
Failure to Follow Menu-Directed Portion Sizes for Mechanical Soft Diets
Penalty
Summary
The facility failed to follow its planned menu spreadsheets and portion guidelines for residents on mechanical soft (dental soft) diets, resulting in incorrect entrée portions being served. The diet menu spreadsheet for a Tuesday (week 2) specified that residents were to receive a 4 oz portion of bacon wrapped beef, and for those on dental soft diets, the spreadsheet directed use of a #8 gray scoop of ground chopped beef steak with gravy, which the facility’s color-coded scoop chart identified as equivalent to 4 oz. During an observed meal service in the kitchen steam table area, the server (V16) instead used a #12 green scoop, equivalent to 3 oz, to serve the ground chopped beef steak to four residents on dental soft diets (R73, R96, R117, and R119), contrary to the menu spreadsheet instructions. The registered dietitian (V17) later confirmed that the scoop size shown on the menu should have been used to ensure residents received the correct portions to meet their planned caloric and nutritional needs, and the diet roster printed shortly before the observation verified that these residents were ordered dental soft (mechanical soft) diets. The deficiency centers on the discrepancy between the facility’s written menu and portion control system and the actual practice observed during meal service, specifically the use of a smaller scoop than prescribed for the main entrée for residents requiring mechanical soft diets.
Failure to Follow Mechanical Soft Diet Guidelines During Meal Service
Penalty
Summary
The facility failed to follow prescribed mechanical soft (dental soft) diet guidance for multiple residents during meal service. During an observed meal on the 2nd floor, several residents with diet orders for dental soft/mechanical soft received whole corn as a vegetable, despite their meal tickets indicating soft and chopped green beans as the selected vegetable option. Another resident on a mechanical soft diet received a 4 oz cup of chopped fruit that included chunks of raw pineapple. The facility’s dietitian later stated that residents on mechanical soft diets are allowed only chopped canned fruits and soft, cooked vegetables, and the Assistant Director of Dining Services confirmed that if green beans were circled, those residents should have received green beans and that pineapple chunks are not served on mechanical soft diets. The facility’s written policy on Mechanical Altered Diets specifies that vegetables must be cooked soft, moist, and fork-tender with no large chunks or pieces, and that only soft, peeled fresh fruits such as peaches, nectarines, melon without seeds, and sliced banana are allowed, indicating that the foods served did not conform to the established mechanical soft diet guidelines. These observations, interviews, and record reviews showed that all reviewed residents on mechanical soft diets did not consistently receive food prepared in a form designed to meet their individual diet orders and the facility’s own mechanical soft diet policy.
Failure to Provide Required ADL Assistance With Feeding and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), including dining and incontinence care, to residents who were unable to perform these tasks independently. One resident with Parkinson’s disease, dysphagia, and documented self-care and functional mobility deficits had a physician order indicating staff should now feed him and a care plan noting inadequate oral intake with an intervention to provide dining assistance as necessary. Despite this, staff repeatedly delivered meal trays without providing feeding assistance or encouragement. On multiple observed occasions in the dining room, the resident ate only portions of the meal and then stated he was done, with no staff assistance or prompting. During a breakfast observation, a CNA left the resident in bed with dry cereal, juice, and milk and did not assist, later stating the resident did not need help, even though the resident consumed only a small portion and spilled most of the juice. The registered dietician stated there was an order for 1:1 feeding and that the resident should be fed in the dining room, while dietary leadership explained that 1:1 feed orders do not automatically appear on diet tickets and rely on nursing to notify dietary and CNAs. Another resident with dementia, a leg fracture, neuropathy, and hip pain had a care plan documenting bowel incontinence with an intervention to check the resident every two hours. Surveyors observed this resident lying in bed in a gown with a strong bowel odor and multiple cups of red-colored beverages on a bedside table initially positioned a few feet away and later over the bed, with flies flying around her. A CNA reported that the last personal care and change for this resident had been provided several hours earlier in the morning. The same CNA later stated that for residents who do not use the call light, she typically checks them for incontinence care at the beginning of the shift, around breakfast and lunch, and every 2.5 to 3 hours, while the DON stated residents should be checked every two hours and as needed. Facility grievance logs and resident council reports over several months documented multiple concerns regarding ADLs. Facility policies on ADLs and incontinence care state that residents unable to carry out ADLs independently will receive appropriate services to maintain good nutrition, personal hygiene, and incontinence care based on individual needs and service plans.
Failure to Assess and Manage Pain During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and manage pain for a resident with a recent left femur fracture and dementia who experienced significant pain during routine care. The resident was admitted with a diagnosis of left femur fracture and post-surgical care, with documentation that she felt pain when turning and complained of left hip pain with movement. Physician orders included monitoring pain level and location each shift and multiple PRN and scheduled analgesic orders, including acetaminophen and hydrocodone-acetaminophen for moderate to severe pain. The care plan documented that the resident was on pain medication therapy related to pain, with an intervention to administer analgesics as ordered. On the observed date, a CNA reported that the resident screamed and yelled when touched, and surveyors observed the resident screaming and yelling in pain and calling for help during incontinence care. The resident’s meal tray remained untouched because she declined to have her bed raised due to pain and preferred not to be moved. The CNA stated she had asked the nurse about pain medication, and the nurse initially told her she did not know if the resident had any medication orders. The nurse later stated she was waiting for the CNA to finish incontinence care before administering pain medication, despite the resident’s active pain medication orders. The DON stated that when a resident exhibits significant pain during incontinence care, the nurse should assess the pain, medicate prior to care if possible, and, if the resident cannot tolerate care, wait and re-approach after pain is addressed. The facility’s policies on ADLs and pain management require recognizing and evaluating pain, anticipating pain with activities such as repositioning, and pre-medicating when possible, which was not done in this case.
Crushing of ER Medication and Omission of Ordered Laxative Result in Elevated Med Error Rate
Penalty
Summary
The deficiency involves failure to follow physician orders and facility policy during medication administration, resulting in a medication error rate above 5 percent. During a medication pass observation, a nurse (V4) administered Metoprolol Succinate ER 50 mg to a resident (R100) by crushing the extended-release tablet before giving it. Facility Medication Crushing Guidelines revised January 2018 state that time-release tablets, which are designed to release medication over 8 to 24 hours, should not be crushed. The facility’s Medication Administration Policy dated June 1, 2023, requires that medications be administered in accordance with written prescriber orders and established procedures. In the same observation and subsequent medication reconciliation, surveyors identified that R100 had a physician’s order for Polyethylene Glycol 3350 (Miralax) 17 grams powder for oral solution on the Medication Administration Record (MAR), but this medication was not administered by V4 during the morning medication pass. When interviewed later that morning, V4 stated that the medications observed being given were the only morning medications the resident had, despite the active Miralax order. Overall, there were 28 medication opportunities with 2 errors, resulting in a 7.14% medication error rate, exceeding the 5 percent threshold.
Failure to Follow Hand Hygiene and Glove-Change Practices During ADL Care
Penalty
Summary
The deficiency involves failure to follow the facility’s infection prevention and control policy regarding hand hygiene and glove use during ADL care. A CNA assisted one resident with toileting and peri care after voiding, then applied a new incontinence brief and pulled up the resident’s pants while continuing to wear the same soiled gloves. Another CNA provided incontinence care to a resident who had a bowel movement, removed the soiled brief, cleansed the perineal area, applied barrier cream, and placed a new incontinence brief without changing gloves during the entire process. In a separate incident, a CNA assisted a resident with dressing while the resident had an indwelling catheter and wore shoes used for wheelchair propulsion. During this care, the CNA touched the catheter bag, the resident’s clothing, the resident’s shoes with dirty soles, and other surrounding surfaces, moving repeatedly between dirty and clean tasks without changing gloves. The DON later stated that staff are required to perform hand hygiene and change gloves when moving from dirty to clean tasks during ADL care. The facility’s written Standard Precautions policy requires hand hygiene after contact with blood, body fluids, excretions, intact skin, and inanimate objects in the resident’s vicinity, and requires changing gloves when moving from a contaminated body site to a clean body site.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to obtain monthly weights and recognize significant weight loss for a resident, resulting in a 12.47% weight loss over 90 days. The resident, who was admitted with a weight of 152 pounds, reported dissatisfaction with the facility's food, describing it as bland and unappealing. Despite a physician's order for monthly weights and a mechanical soft diet, the resident's weight was not consistently documented, and no supplements were provided. The resident's weight was last accurately recorded on 5/9/24 at 143.6 pounds. Subsequent weights were either struck out or not documented, with no accepted weight recorded until 8/7/24, when the resident weighed 125.7 pounds. The Clinical Nutrition Manager/Dietician had requested reweights multiple times via email, but these requests were not acted upon, and the resident's significant weight loss went unrecognized. The Director of Nursing acknowledged the oversight, citing communication issues and staff changes as contributing factors. The facility's policy required monthly weights and reweights for significant changes, but these procedures were not followed, leading to the resident's weight loss going unnoticed. The resident's care plan included monitoring weight and honoring food preferences, but these interventions were not effectively implemented.
Deficiencies in Food Storage and Expiration Management
Penalty
Summary
The facility failed to manage food storage and expiration effectively, impacting all 98 residents who consume food from the kitchen. During an inspection, expired food items were found in the dry storage area, including peanuts, pistachios, almonds, and a dessert sauce. The dietary manager acknowledged that it is everyone's responsibility, especially the stock person, to check and discard expired food items. Additionally, the freezer contained opened provolone cheese without a date or label, which the dietary manager admitted should have been labeled and discarded. Further observations revealed significant ice buildup around the walk-in freezer door, floor, and on food packages, including meat rolls and white fish. The chef, a contracted worker, stated that maintenance had been notified weeks ago about the condensation issues, but no action had been taken despite a work order being placed. The facility's Food and Supply Storage policy requires covering, labeling, and dating unused portions, as well as discarding food past its expiration date, which was not adhered to in this instance.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for residents who were dependent on staff for personal hygiene and grooming. This deficiency was observed in 10 out of 10 residents reviewed for ADLs in a sample of 34. Residents were found with long, unkempt fingernails, some with a dark substance underneath, and female residents with facial hair, which they expressed a desire to have removed. Despite the residents' needs and preferences being documented in their care plans, the staff did not provide the necessary assistance. For instance, one resident was observed with long chin hairs and expressed a desire for them to be removed, but the staff did not assist. Another resident had long, dirty fingernails with a dark substance underneath, and despite expressing a desire for nail care, the staff did not provide the necessary assistance. The facility's policy stated that residents unable to perform ADLs independently should receive the necessary services to maintain grooming and personal hygiene, yet this was not adhered to. Interviews with staff, including CNAs and the Director of Nursing, confirmed that residents should not have long or dirty fingernails and that female residents should not have facial hair for dignity reasons. The staff acknowledged their responsibility to provide grooming and personal hygiene assistance, yet the observations and resident statements indicated a failure to meet these expectations. The facility's policy also emphasized the importance of providing care in accordance with the residents' care plans, which was not followed in these instances.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols during incontinence care, wound care, and meal service, affecting six residents. A CNA was observed delivering meals to residents without wearing gloves and failed to clean her hands between tasks, such as adjusting personal items and cutting food. This lack of hand hygiene was consistent across multiple interactions with residents, including handling personal items and food without cleaning hands or changing gloves. During wound care for a resident, a wound care nurse and a CNA did not follow proper infection control procedures. The CNA did not wear a gown while assisting with wound care, and the nurse failed to clean her hands after removing gloves and before applying new ones. Additionally, the nurse left the room without removing her gown and gloves, and the CNA touched various surfaces with dirty gloves. These actions were contrary to the facility's hand hygiene policy, which mandates hand cleaning between resident contacts and after handling contaminated objects. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them. A wound care nurse did not wear a gown while providing care to residents on EBP, despite the facility's policy requiring PPE during high-contact care activities. This oversight was acknowledged by the staff involved, who admitted to not following the necessary precautions. The facility's policies clearly outlined the need for PPE during wound care, yet these guidelines were not followed, leading to potential cross-contamination and infection risks.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents, which is a critical aspect of accommodating their needs and preferences. This deficiency was observed in three residents, each with significant medical conditions and cognitive impairments. For instance, one resident with type 2 diabetes, dementia, and other serious health issues was left without access to a call light after receiving incontinence care. Another resident, who had congestive heart failure and moderate cognitive impairment, was found with their call light underneath the blankets, out of reach. A third resident, who was cognitively intact but required substantial assistance for daily activities, had their call light hanging off the side of the bed, making it inaccessible. Interviews with staff, including CNAs and the Director of Nursing, confirmed that call lights should always be within easy reach of residents, whether they are in bed or in a chair. The facility's policy also mandates that call lights be accessible to residents at all times. Despite this, the observations on the specified date revealed that the staff did not consistently adhere to this policy, resulting in residents being unable to call for help when needed. This oversight in ensuring the availability of call lights poses a significant risk to resident safety, particularly for those with mobility and cognitive challenges.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite two residents, R45 and R68, to their care plan meetings, which is a requirement for ensuring resident involvement in their own care. R45 reported that she had not attended or been invited to a care plan meeting since her admission to the facility. Similarly, R68 and her son, V8, confirmed that neither had been invited to or attended any care plan meetings since R68's admission. The facility's records lacked documentation of any invitations or attendance for these residents and their representatives. The facility's policy mandates that residents and their representatives be involved in developing and revising care plans, with documentation required if their participation is deemed impractical. However, during the survey conducted from August 6 to August 8, 2024, no such documentation was found for R45 and R68. The facility administrator acknowledged the requirement for resident and representative involvement and documentation but could not provide evidence of compliance for these two residents.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the preferences and needs of two residents, as required by their comprehensive assessments and care plans. Resident R45 reported that she was not offered any activities while in her room, despite her care plan indicating a preference for in-room activities and pop-in visits. Documentation showed only three activity entries over a month, and the Life Enrichment Director confirmed that staff are expected to offer and document daily activities, which was not done in this case. Similarly, Resident R68 expressed dissatisfaction with the lack of activities provided, specifically mentioning a desire to play computer games. Her care plan also indicated a preference for in-room activities and pop-in visits, yet documentation showed only four entries over a month. Staff interviews revealed that activities were not consistently offered to residents who stayed in their rooms, contradicting the facility's policy to support residents' activity choices. The facility's administrator acknowledged that activity staff should check on all residents daily to maintain their quality of life.
Failure to Provide Restorative Nursing Programs for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide restorative nursing programs to residents identified with limited range of motion, affecting three residents in the sample. Resident R53, who was observed in bed with limited range of motion in both arms and inwardly turned feet, reported not receiving exercises from the facility. The Director of Rehab confirmed that R53 was discharged from occupational therapy with recommendations for an active range of motion restorative nursing program, but no such program was implemented. R53's medical history included multiple diagnoses such as polyosteoarthritis and muscle weakness, and the MDS indicated functional limitations in both upper and lower extremities. Resident R8, observed in a wheelchair and unable to raise her right arm, also reported inconsistent assistance with exercises. Her medical history included conditions like diabetes and congestive heart failure, and the MDS showed moderate cognitive impairment and functional limitations in both upper and lower extremities. Despite these needs, R8 did not have physician orders or care plans for restorative nursing programs. Resident R55, with a dislocated left shoulder and multiple diagnoses including Parkinson's Disease and muscle weakness, expressed a desire for exercises to prevent further decline. The Director of Nursing acknowledged the absence of a restorative nurse and stated that restorative programs were not being carried out, despite recommendations from therapy. The facility's policy emphasized the importance of restorative services, but these were not being provided, leading to potential declines in residents' conditions.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall mats were properly placed for a resident identified as being at high risk for falls. Observations over several days revealed that the resident's fall mats were either folded against the wall or only placed on one side of the bed, and the bed was not consistently in the lowest position. Interviews with multiple CNAs and an LPN confirmed that the standard practice for residents at high risk of falls includes having fall mats on both sides of the bed, the bed in the lowest position, and frequent monitoring. However, these measures were not consistently implemented for the resident in question. The resident, who was admitted with conditions such as aphasia, atherosclerosis, a fracture of the right femur, hypertension, cognitive communication deficit, muscle weakness, and anemia, was noted to be cognitively intact. The resident's care plan, which included interventions like bilateral floor mats due to a high risk of falls, was not followed as observed. The facility's Fall Prevention and Management policy outlines the development of a comprehensive fall prevention care plan, but the facility was unable to provide a specific Fall Intervention policy when requested.
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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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