Goldwater Care Clinton
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Illinois.
- Location
- 1 Park Lane West, Clinton, Illinois 61727
- CMS Provider Number
- 146076
- Inspections on file
- 52
- Latest survey
- March 21, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Goldwater Care Clinton during CMS and state inspections, most recent first.
The facility failed to protect cognitively impaired residents from physical abuse by another resident with known aggressive behaviors. One resident with poor vision and wandering behavior sustained a bruising and a 5 cm by 3 cm skin tear to the right forearm after a physical altercation with an aggressive resident, as witnessed by an LPN and documented in behavior notes. Staff, including CNAs and an activity aide, described the aggressive resident as verbally and physically aggressive toward staff and sometimes attempting to become physical with other residents. Another cognitively impaired resident with care-planned verbal/physical aggression and hoarding/rummaging behaviors was also documented as having an altercation with the same aggressive resident. These incidents occurred despite the facility’s written abuse prevention policy prohibiting abuse and affirming residents’ right to be free from abuse.
The facility failed to report an alleged resident-to-resident altercation to the State Agency as required by its abuse reporting policy. One resident with dementia, depression, poor impulse control, and a history of verbal/physical aggression, and another resident with Alzheimer’s disease, mood disorder, vascular dementia, anxiety, hoarding/rummaging behavior, and verbal/physical aggression were involved in an alleged altercation documented by an LPN. The nurse’s note did not show notification to the abuse coordinator, and the Administrator later stated he did not report the incident because he was unaware of it, even though staff interviews confirmed ongoing aggressive behaviors and the facility’s policy required reporting all abuse allegations to public health authorities.
The facility failed to investigate an alleged physical altercation between two residents with severe cognitive impairment and documented histories of verbal/physical aggression and problematic behaviors. Nursing notes recorded that one resident had an alleged physical altercation with another, and an LPN documented the same incident without notifying the abuse coordinator. Despite a written abuse policy requiring that all incidents be documented and any allegation involving abuse be investigated, the Administrator later stated that no investigation occurred because the incident was not reported to administration.
Surveyors found that the facility failed to follow its fall prevention policy and resident care plans, resulting in multiple accidents and injuries. A resident with dementia and Parkinsonism, known to require close supervision, was left unsupervised in a dining room, stood up to sweep, and fell, sustaining a head laceration and clavicle fracture while on anticoagulant therapy. Another fully dependent resident was transferred to a shower chair with a mechanical lift, but staff left the sling under the resident and moved the chair; the sling straps caught in the wheels, the resident slid from the chair, and suffered a fractured tailbone. A third resident with severe cognitive impairment and high fall risk fell in a bathroom when a CNA turned away, striking a loose towel bar at head height and sustaining facial injuries; no post-fall risk assessment or care plan update was completed. Additional residents had care-planned fall interventions, such as floor mats, a concave mattress, non-skid strips, and task-based activities, that were not implemented or communicated to staff.
The facility failed to ensure accurate transcription and administration of medications for three residents. One resident with dementia and major depression had a psychiatric order to continue daily Quetiapine 50 mg plus PRN dosing, but the scheduled dose was erroneously discontinued in the MAR, resulting in 13 missed days of the antipsychotic and escalating agitation and aggressive behavior. Another resident with Parkinson’s disease received Carbidopa/Levodopa three times daily without regard to meals, despite the physician’s statement that dosing 30–60 minutes before meals is crucial for absorption and that improper timing was likely contributing to worsening Parkinsonian symptoms. A third cognitively intact resident did not receive any scheduled evening medications, including antihypertensives, anticoagulant, antiseizure, and other drugs, because an agency nurse left the full medication cup on a dresser and the doses were discovered untouched the next day.
The facility did not ensure required RN coverage for at least eight consecutive hours daily and lacked consistent full-time DON coverage. The administrator stated there was no stand-alone staffing policy and that the facility followed minimum staffing guidelines, with nurses working 12-hour shifts. Staffing records showed multiple days with no RN scheduled or available, and the former DON reported that an RN was not always present, especially on weekends, and that agency RNs were not consistently available to cover open shifts. At the time, 104 residents were documented as residing in the facility.
A resident admitted for post‑surgical pain control after a total knee replacement arrived with multiple ordered pain medications and specific transfer needs but was not greeted promptly, was left without access to a call light, was instructed by a CNA to ambulate independently despite requiring assist with a gait belt, and was not assessed or medicated for severe pain by an LPN because controlled substance prescriptions were not faxed to the pharmacy and the admission process was not completed, leading to uncontrolled pain until transfer to the ER. In a separate case, another resident with COPD and pneumonia had a chest X‑ray showing right lung base opacities consistent with possible pneumonia; although nursing staff contacted the physician and received orders for antibiotics and DuoNeb, the MAR shows the antibiotic was not administered until four days after the X‑ray results were reported, delaying treatment and prolonging symptoms.
The facility failed to adequately supervise cognitively impaired residents at high risk for falls and did not complete thorough fall assessments and investigations. One resident with dementia and severe cognitive impairment, who required staff assistance for transfers, sustained two unwitnessed falls in common areas while not under direct supervision, each time attempting to self-transfer from a wheelchair without brakes applied, resulting in significant head hematomas, pain, and emergency transfers. Another severely cognitively impaired, bed-bound resident experienced multiple falls from bed, including events involving rolling out of bed onto a floor mat and being found hanging from a side rail, without completion of fall risk assessments, thorough root-cause investigations, required 72-hour neuro checks, side-rail assessments, or documented safety checks, despite a written fall prevention policy.
A resident with chronic pain and recent total knee replacement was admitted for post‑surgical pain control with orders for multiple opioids and muscle relaxants, but staff failed to ensure these medications were available or administered upon admission. The resident reported severe pain soon after arrival and again later in the evening, yet an LPN did not provide pain medication or effective intervention, and subsequent call‑light requests brought no relief. Near midnight, another LPN assessed the resident and discovered that controlled substance prescriptions had never been faxed to the pharmacy, leaving no ordered pain meds in the building or emergency supply. The resident, in extreme uncontrolled pain and visibly distressed, requested transfer and was sent to the ED for treatment of uncontrolled pain.
The facility failed to ensure that an RN was on duty for at least eight consecutive hours each day, despite a census of over 100 residents and a facility assessment stating that daily RN coverage was needed to provide competent support and care. Review of staffing schedules over several weeks showed multiple days without the required RN coverage, and the DON confirmed that the facility did not consistently meet the eight-hour RN requirement and needed additional RNs to do so.
Multiple cognitively intact residents who were incontinent of bowel and/or bladder reported that staff, particularly agency CNAs on night shift, failed to respond to call lights and did not perform regular incontinence checks, leaving them in saturated briefs and soiled bed linens for hours. One resident described activating the call light several times overnight without assistance and remaining in urine-soaked bedding until morning, while day-shift CNAs reported repeatedly finding residents with wringing-wet briefs and linens showing multiple rings of dried and fresh urine and feces, indicating a lack of overnight rounds. Another resident with diarrhea and requiring a full-body mechanical lift was told by two CNAs that she could not get up and would not be changed, until a CNA who witnessed this cleaned her and reported the incident to an RN, who later acknowledged it was a dignity issue. Other residents stated that when agency staff worked nights, they were not checked, were left in their incontinence, and felt horrible and like a burden.
The facility failed to honor residents’ preferences for shower timing and did not consistently provide or document scheduled showers for multiple cognitively intact residents who required assistance with bathing. Several residents with conditions such as muscle wasting, gait abnormalities, multiple sclerosis, epilepsy, chronic pain, and morbid obesity reported not receiving the two showers per week they were told they would get, with some describing long gaps between showers and being offered showers at unacceptable hours, such as in the middle of the night. Shower sheets frequently lacked documentation that showers were offered, completed, or refused, and when refusals were noted, reasons and follow-up attempts were often missing. CNAs, including agency staff, reported that some residents rarely received showers because they took a long time to bathe, and the DON acknowledged ongoing issues with showers not being done or properly documented despite a policy requiring showers according to resident preference at least twice weekly.
The facility failed to ensure timely ordering, receipt, and administration of medications, including controlled substances for pain, resulting in multiple missed doses for three cognitively intact residents. One resident admitted after a total knee replacement did not receive any ordered pain medications overnight because controlled substance prescriptions were not faxed to the pharmacy upon admission, leaving no medications available in the emergency supply. Two other residents experienced repeated missed doses of antidepressants, anticonvulsants, hormone cream, antihypertensives, and additional antidepressants documented as out of stock or unavailable from the pharmacy. An LPN, the ADON, the DON, and the pharmacist all confirmed that orders were not consistently placed in advance, prescriptions were not transmitted as required, and there were ongoing problems with the medication distribution system and timely pharmacy delivery.
A resident with chronic pain, vertebral compression fractures, muscle wasting, and mobility abnormalities, and with intact cognition and documented moderate pain, had an order for Methocarbamol 750 mg PO three times daily for pain. Over several days, multiple scheduled doses were not administered, with the MAR and nursing notes repeatedly indicating the medication was on order, awaiting pharmacy, out of stock, or unavailable. The resident reported near-constant deep muscle pain and stated that the muscle relaxer was not consistently available or given as scheduled, despite also receiving hydrocodone. The DON later acknowledged that the resident had missed several doses of the ordered Methocarbamol and described this as a significant medication error.
Two residents were affected when the facility failed to implement droplet isolation precautions for a resident with active, symptomatic pneumonia. A chest X-ray confirmed pneumonia, and antibiotics were ordered and later administered, but no isolation orders or care plan entries for infection control were documented, and droplet precautions were never initiated during the illness and treatment period. The coughing resident was placed in a shared room with another resident who did not have pneumonia, and staff did not use gowns or masks, despite a facility policy allowing nursing leadership and the infection preventionist to initiate transmission-based precautions without a physician order.
A resident admitted for post-surgical pain control after a total knee replacement experienced severe, uncontrolled pain when ordered opioid and muscle relaxant medications were not available from the pharmacy or emergency supply. Over several hours, the resident repeatedly reported severe knee pain, became tearful and shaking, and requested transfer to the ER, yet the assigned LPN did not notify any physician about the pain escalation, the lack of ordered medications, or the resident’s request for hospital transfer, stating she was unsure who the physician was. Documentation lacked evidence of physician notification despite facility policy requiring notification for significant changes in condition and for transfers.
A resident with intact cognition reported that a CNA threw clothes at her and told her to dress herself and get into her wheelchair on her own, leaving her upset and feeling abused. The concern was documented on a grievance form and relayed by a housekeeping supervisor to the Administrator/Abuse Prevention Coordinator, who treated it as a customer service issue rather than an abuse allegation. The facility’s abuse policy requires that any abuse allegation be reported to the State Agency within specified time frames, but this allegation was not reported as required.
The facility did not have an RN on duty for at least eight consecutive hours on multiple days, as confirmed by administrative staff and assignment records, despite maintaining a census of 104 residents.
Three dependent residents with significant medical conditions did not receive all scheduled showers, and staff failed to document missed showers or refusals as required by facility policy. Interviews with the administrator and DON confirmed that showers should be provided and documented twice weekly, but records showed multiple missed or undocumented bathing opportunities.
A resident with dementia and a malignant breast neoplasm did not receive multiple ordered wound dressing treatments, and repeated refusals for wound care were not properly addressed or documented. The DON confirmed that staff did not follow required procedures for completing treatments and notifying the physician when treatments were missed or refused.
A resident with a history of aggression, psychiatric issues, and cognitive impairment physically contacted another resident's upper thigh while that resident was in their bed. Staff and administrative interviews confirmed ongoing aggressive behaviors by the resident, and the care plan documented these risks, but the facility did not prevent the incident.
A resident with cognitive impairment and high fall risk experienced a fall that was not promptly reported or investigated by facility staff. Confusion among the DON, ADON, and Administrator led to delayed recognition and documentation of the incident, contrary to facility policy requiring immediate reporting and investigation of accidents.
An audit identified 40 instances of inaccurate ADL documentation for five residents, including false charting of care such as baths not actually provided. The mis-documentation was confirmed through record review and staff interviews.
Multiple residents with complex medical needs experienced delayed call light responses, missed showers, and late blood work due to inadequate staffing and lack of necessary supplies. Facility records and interviews confirmed that agency CNAs often failed to complete assigned tasks, leading to ongoing resident and family complaints about care quality.
Several residents were provided with incontinence briefs that did not fit or were unavailable due to supply shortages, and staff confirmed that the facility ran out of various sizes of briefs over a weekend. Ongoing shortages of washcloths were also reported by residents and staff, with some staff using bath towels as substitutes and observations confirming a lack of washcloths in multiple areas.
The facility did not consistently provide ordered wound care or accurately document the progression of pressure injuries for three residents. In one case, a wound was not reclassified after physician evaluation, and in multiple cases, ordered dressing changes were missed and not documented as completed.
Two residents did not receive multiple prescribed medications as ordered, with missed doses documented for anti-seizure, blood pressure, antiplatelet, and diabetic medications. The DON was unable to explain the missed administrations, and the facility's policy requiring timely medication administration and documentation was not followed.
A resident with epilepsy did not receive her anti-seizure medications on time and, when she asked about them, an agency nurse responded curtly that she would 'just have to have a seizure.' The LPN later admitted to being overwhelmed and curt, and the DON acknowledged the response was harsh. The resident reported feeling disrespected and undignified due to the incident.
Two residents did not receive multiple prescribed medications on several occasions, as documented by gaps in the MAR. One resident, who was cognitively intact, reported missed doses often occurred in the evening with agency nurses. The DON was unable to explain the missed doses and confirmed that undocumented medications were not given.
The facility failed to employ a clinically qualified Director of Activities, affecting all 77 residents. The current Director, responsible for managing the activity department, is not certified and uncertain about enrolling in a certification course. Despite actively managing staff, this lack of certification was confirmed by another staff member.
The facility failed to provide and implement activities for residents in the Memory Care Unit, affecting five residents with dementia and anxiety. Observations showed residents were left without group activities or individual engagement, and their participation was not documented. Staff interviews revealed a lack of dedicated activity personnel and insufficient time for Memory Care Specialists to conduct activities due to staffing issues.
The facility failed to conduct thorough investigations and implement post-fall interventions for three residents who experienced falls, resulting in injuries such as lacerations and a refractured femur. Despite multiple incidents, care plans were not updated with new interventions, and there was a lack of documentation for fall investigations and root cause analyses.
The facility failed to address grievances about CNAs using cell phones during care, as documented in Resident Council Minutes from January to November 2024. Despite repeated complaints, residents reported ongoing issues with CNAs using phones and ear buds, being loud, and displaying rude attitudes. Interviews with residents confirmed dissatisfaction with the facility's response, and the administrator acknowledged awareness of the issue.
The facility failed to document registry verification for several employees, including CNAs, before their start dates, potentially affecting all 90 residents. The Human Resource Manager was unable to locate evidence of registry checks, which were only added after employment began.
The facility's assessment failed to include essential equipment and medications, affecting all 90 residents. Mechanical lifts, used by 18 residents, and narcotic medications, prescribed to multiple residents, were omitted. The Assistant Director of Nursing and the Administrator confirmed these omissions.
The facility failed to maintain infection control in its laundry services and did not properly manage a COVID-19 outbreak. A laundry aide did not use appropriate PPE, and staff were not informed timely about the outbreak. Observations showed improper PPE use, and the facility did not notify the local health department. Multiple residents tested positive for COVID-19, and communication with staff was inadequate.
The facility did not document the education, offering, and consent or declination of COVID-19 vaccines for staff, potentially affecting all 90 residents. A review of staff files, including those of LPNs and CNAs, showed no evidence of these actions. The new HR Manager and staff confirmed the absence of documentation, indicating a lapse in record-keeping practices.
The facility failed to implement accurate care plans for residents, omitting critical medical conditions and treatments. One resident's pressure ulcers and medications were not documented, another's oxygen therapy was missing from their plan, and a third's care plan incorrectly noted a knee replacement instead of a vascular disorder. Additionally, a resident with ALS had communication needs unaddressed.
The facility failed to assess and document the administration of pneumococcal and influenza vaccines for four residents. Incomplete or missing consent forms and lack of documentation in the MAR were noted, despite face sheets indicating vaccine administration. A staff member confirmed that undated consents are invalid and lack of documentation suggests vaccines were not administered.
The facility failed to submit the MDS in a timely manner for a resident, with assessments and care plans completed late on two occasions. The Care Plan Coordinator and Corporate Care Plan Consultant confirmed the delays, which were not in accordance with the facility's policy requiring comprehensive care plans to be developed within seven days after the MDS assessment.
A facility failed to accurately complete a comprehensive assessment for a resident. The MDS indicated the resident was taking an anticoagulant, but there was no corresponding physician order. A staff member confirmed the error, acknowledging the MDS was incorrectly coded.
The facility failed to conduct level II PASARR for two residents with newly diagnosed serious mental disorders. One resident was diagnosed with unspecified psychosis and prescribed Seroquel, while another was diagnosed with paranoid schizophrenia and also prescribed Seroquel. Both residents lacked a level II screening in their medical records, as confirmed by the Director of Nurses and the Administrator.
The facility failed to administer insulin according to manufacturer's directions for three residents. Insulin was given well before meals, contrary to instructions requiring administration shortly before eating. An LPN confirmed no nourishment was provided between insulin administration and meal service.
A facility failed to provide an effective communication program for a resident with ALS, who is cognitively intact but speaks softly. The resident expressed that staff do not take the time to listen, assuming he cannot communicate. An LPN confirmed the absence of a communication plan, and the resident's care plan did not address his communication needs, contrary to the facility's policy.
The facility failed to assess and implement necessary interventions for pressure ulcers for two residents. One resident developed a stage II ulcer without a pressure-relieving mattress, and their care plan was not updated. Another resident was observed with undated dressings and an error light on the air mattress, with missing treatment administrations and an incomplete care plan. These actions indicate non-compliance with pressure ulcer prevention policies.
The facility failed to date and label oxygen equipment for three residents, as required by their policy. Observations showed undated nasal cannulas and humidifier bottles, with some bottles empty or not attached. Staff confirmed the policy was not followed.
A facility failed to monitor the bowel function of a resident receiving hydrocodone-acetaminophen, an opioid medication, as part of their drug regimen. The resident's care plan did not include interventions for monitoring bowel movements, and there was no documentation of bowel function monitoring despite the resident receiving the medication multiple times. The DON confirmed the lack of a monitoring system for residents on narcotics, and the Administrator verified the absence of a specific policy for narcotic medication monitoring.
The facility failed to obtain consent, assess, and monitor two residents receiving psychotropic medications, and did not document non-pharmacological interventions. One resident's records lacked assessments and behavior tracking, while another's care plan did not document medication use or interventions. Additionally, there was no attempt at gradual dose reduction, and the consent for lorazepam was outdated.
A facility failed to conduct timely A1C tests for a resident with type two diabetes mellitus, as ordered by a physician. The resident's medical records lacked documentation of A1C tests on the specified dates in February and August, with only one test conducted in October. Interviews with the Director of Therapy and the DON confirmed the oversight.
The facility failed to update care plans for three residents after significant events, including falls with injuries and new pressure ulcers. One resident's care plan did not reflect a new pressure ulcer, another's did not document falls or post-operative precautions, and a third's lacked fall interventions despite multiple incidents. Family members expressed concerns over the lack of preventive measures, and the DON confirmed the absence of necessary updates.
Failure to Protect Cognitively Impaired Residents From Peer-to-Peer Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively impaired residents from physical abuse by another resident with known aggressive behaviors. One resident (R1), who is cognitively impaired with poor vision and a history of wandering into other residents’ rooms and beds, was documented in a behavior note dated 2/27/2025 as having an alleged physical altercation with another resident (R2), resulting in bruises and a skin tear to the right forearm measuring 5 cm by 3 cm. An LPN (V6) reported witnessing this physical altercation on the evening of 2/27/2026 and confirmed that R1 sustained a skin tear from the incident. R1’s family member (V7) stated they were notified of this altercation and the resulting skin tear. During observation on 3/21/2026, R1 was seen wandering independently around the dining room and had a healed wound on the right forearm, and staff interviews confirmed R1 is usually verbally, but not physically, aggressive. The same aggressive resident (R2), who has severely impaired cognition per the MDS and is care planned for potential physical aggression related to anger, dementia, depression, history of harm to others, and poor impulse control, was repeatedly described by staff as verbally and physically aggressive, particularly toward staff and sometimes toward other residents. A CNA (V4) and an activity aide (V5) reported that R2 can become aggressive when frustrated or overstimulated, with V5 noting that R2 sometimes attempts to get physical with other residents and that staff usually remove R2 before this occurs. R2’s nurse’s notes and behavior notes dated 2/25/2026 and 2/27/2026 document alleged physical altercations with other residents. Another cognitively impaired resident (R5), who has care plans for problematic behaviors including verbal/physical aggression and hoarding/rummaging related to dementia and mood disorders, was also documented in a nurse’s note dated 2/25/2026 as having an alleged altercation with R2. Despite the facility’s written Abuse Prevention and Reporting Policy affirming residents’ right to be free from abuse and prohibiting abuse, these documented altercations show that residents R1 and R5 were not protected from physical abuse by R2.
Failure to Report Alleged Resident-to-Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-to-resident abuse to the State Agency as required by its Abuse Prevention and Reporting Policy. The facility’s policy, revised 10/24/22, states that when an allegation of abuse has occurred, the resident’s representative and the Department of Public Health’s regional office shall be informed by telephone or fax, and Public Health shall be informed that an occurrence of potential abuse has been reported and is being investigated. A nurse’s note dated 2/25/2026 by an LPN documented that one resident (R5) had an alleged altercation with another resident (R2), but the note did not document any notification to the abuse coordinator. The Administrator later stated that he did not report the incident between these two residents because he was not aware of it and that staff should have reported it to him. The residents involved had known behavioral issues and cognitive impairments documented in their care plans and assessments. One resident (R2) had care plans initiated on 8/25/2025 and 3/2/2026 indicating problematic behavior characterized by ineffective coping, verbal and physical aggression related to cognitive impairment and physiological brain changes, and a potential to be physically aggressive related to anger, dementia, depression, history of harm to others, and poor impulse control. Staff interviews described this resident as verbally and sometimes physically aggressive, primarily toward staff, with attempts to become physical with other residents. The other resident (R5) had care plans initiated on 3/3/2026 documenting problematic behavior with verbal and physical aggression related to cognitive impairment, Alzheimer’s disease, mood disorder, vascular dementia, anxiety, and inability to differentiate others’ belongings, as well as hoarding and rummaging behaviors. A RN described this resident as usually angry and mostly verbally aggressive. Despite these documented behaviors and the alleged altercation between the two residents, the incident was not reported to the State Agency as required by facility policy.
Failure to Investigate Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident physical abuse involving two residents with known histories of aggression and cognitive impairment. The facility’s Abuse Prevention and Reporting Policy, revised 10/24/22, states that all incidents will be documented whether or not abuse is alleged or suspected, and that any incident or allegation involving abuse will result in an investigation. Nursing notes dated 2/25/2026 document that one resident (R2) had an alleged physical altercation with another resident, and another note from the same date by an LPN documents that a second resident (R5) had an alleged altercation with R2. The nurse’s note for R5 does not document any notification to the abuse coordinator. R2’s care plans, initiated 8/25/2025 and 3/2/2026, identify a problematic manner of acting characterized by ineffective coping and verbal/physical aggression related to cognitive impairment and physiological brain changes, as well as a potential to be physically aggressive related to anger, dementia, depression, history of harm to others, and poor impulse control. R2’s MDS shows a BIMS score of 02, indicating severely impaired cognition. R5’s care plans, both initiated 3/3/2026, document problematic behavior characterized by ineffective coping, verbal/physical aggression, and inappropriate behavior such as hoarding and rummaging, related to cognitive impairment, onset of Alzheimer’s, mood disorder, vascular dementia, anxiety, and inability to differentiate between personal and others’ belongings. On interview, the Administrator stated that the incident on 2/25/2026 between R2 and R5 was not investigated because the Administrator was not aware of it and staff had not reported it, resulting in no investigation of the alleged abuse as required by policy.
Failure to Prevent Falls and Remove Hazards Leads to Multiple Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and fall prevention interventions for multiple residents, contrary to its Fall Prevention Program policy. The policy requires assessment of fall risk, implementation of appropriate interventions, adherence to professional standards and manufacturer recommendations, and completion of fall risk assessments after any fall. For one resident with moderate cognitive impairment, Parkinsonism, and dementia, the MDS documented an inability to safely ambulate ten feet and a care plan identifying a risk for falls with interventions including frequent checks and increased supervision during mealtimes. Despite this, the resident was left in the dining room without staff present, attempted to stand and sweep with a broom, lost balance, and fell, sustaining a head laceration and an acute distal clavicle fracture while on anticoagulant therapy. Staff interviews confirmed that this resident requires very close, often constant, supervision and that there should always be staff present in the dining room, but staff acknowledged that the resident was left unsupervised at the time of the fall. Another deficiency involved a resident with multiple sclerosis, demyelinating disease of the CNS, muscle wasting and atrophy, polyneuropathy, and abnormal posture, who was dependent on staff for all mobility and required substantial to maximal assistance with bathing. This resident was transferred to a shower chair using a mechanical lift by a CNA and an LPN, and the mechanical lift sling was left under the resident. The CNA then attempted to move the shower chair without removing the sling or securing the sling straps, which became caught in the wheels, causing the chair to stop abruptly and the resident to begin sliding forward. The CNA tried to hold the resident in the chair and called for help; the LPN and another CNA responded, but before they could use the lift to reposition the resident, the resident slid or was dropped to the floor and was later diagnosed with a new angulation at the sacrococcygeal junction consistent with a broken tailbone. Staff interviews confirmed that leaving the sling under the resident was common practice and that only one staff member typically assisted with the resident’s bath, despite the resident’s total dependence for ADLs. A further deficiency concerned a resident with dementia, syncope, difficulty walking, muscle wasting and atrophy, pain, cognitive communication deficit, depression, and anxiety, who had severely impaired cognition and required substantial to maximal assistance for transfers. This resident had a documented fall risk and a prior unwitnessed fall, and later experienced a fall in the bathroom when a CNA turned away after assisting from the toilet to a wheelchair. While the CNA turned to back the wheelchair out, the resident rose from the wheelchair, reached for a towel bar located above and to the right of the grab bar, and fell into it, causing a facial laceration, swelling, and a hematoma extending from the cheek to the neck, requiring emergency department evaluation, CT imaging, and adhesive skin closures. The fall investigation and staff interviews confirmed that the CNA had turned away from the resident, that the towel bar at head height remained in place and was loose and dislodged, and that the towel bar was recognized as a safety hazard. The resident’s care plan was not revised with a targeted intervention after this fall, and no post-fall risk assessment or 72-hour follow-up charting was documented, despite facility policy requiring a fall risk assessment after any fall and care plan updates addressing each fall. Additional deficiencies involved failures to implement existing fall-prevention care plan interventions for other residents. One resident’s fall prevention care plan required floor mats on each side of the bed when the resident was in bed, but observations on two occasions showed the resident in bed with no fall mat on one side and a mat leaning against the wall instead. Another resident, identified as high risk for falls, had care plan interventions for a concave mattress, non-skid strips by the bed, and provision of working tasks as activities. Observations showed the resident lying on a regular mattress without a concave mattress or non-skid strips in place, and later sitting in a television room without any working task activity. A CNA who regularly cared for this resident reported never seeing a concave mattress or non-skid strips in use, and the activity aide stated she was not familiar with the working task intervention and that such interventions were not always communicated to her. The administrator confirmed that the concave mattress and non-skid strips should have been implemented and that the working task intervention was unclear and not conveyed to activity staff.
Medication Transcription, Timing, and Administration Failures Affecting Three Residents
Penalty
Summary
The deficiency involves multiple failures in medication management, including inaccurate transcription of an antipsychotic order, improper timing of an antiparkinsonian medication in relation to meals, and failure to ensure medications were actually taken by a resident. One resident with diagnoses including Type II diabetes, Alzheimer’s dementia, repeated falls, and major depression had a psychiatric visit on 12/10/25, during which the psychiatric provider ordered continuation of Quetiapine 50 mg daily for agitation related to dementia and added Quetiapine 25 mg every 6 hours PRN. However, the resident’s Medication Administration Record and current physician order sheet show that the scheduled Quetiapine 50 mg dose was discontinued in error on 1/28/26, and no PRN doses were administered. As a result, the resident missed 13 consecutive days of the antipsychotic until the surveyor identified the error. During this period, staff and the psychiatric provider described escalating agitation, aggressive behavior, cursing, shouting, refusal of care, and isolation, and the psychiatric PA stated it was never the intention to stop the Quetiapine and that abrupt cessation likely contributed to the behavioral escalation. Another resident, with diagnoses including depressive disorder, history of right femur fracture with hip replacement, and Parkinson’s disease, was ordered Carbidopa/Levodopa (Sinemet) 25/100 mg three times daily for Parkinson’s disease with dyskinesia and fluctuations. The resident’s family reported being instructed that the medication should be given 30–60 minutes prior to food because high-protein foods interfere with absorption, but stated that in the facility it was sometimes given before, sometimes after, and sometimes with meals. The MAR documented the three-times-daily Sinemet order without specific meal-related instructions, and the primary physician confirmed that timing 30–60 minutes prior to meals is crucial for absorption and that incorrect timing could be causing increased Parkinson’s symptoms. The acting DON confirmed that this resident’s Sinemet had been administered without regard to meals, while nursing staff described a general practice of administering medications within one hour before or after scheduled times due to workload. A third resident, documented as cognitively intact, reported that on a Sunday evening an agency nurse left all of the resident’s evening medications in a cup on the dresser for the empty bed next to the resident, and the resident did not remember to take them. The next day, an activity assistant found the untouched medications, and the acting DON verified they were all of the resident’s 8:00 p.m. medications. The MAR showed that these evening medications included multiple critical drugs: Amlodipine and Lisinopril (antihypertensives), Atorvastatin (anticholesterol), Eliquis (anticoagulant), Keppra (antiseizure), Metoprolol (beta blocker), as well as Famotidine and Senna. The administrator confirmed that the resident did not receive any of the scheduled 8:00 p.m. medications that night because they had been left in the cup on the dresser by the agency nurse. The facility’s policy on entering and processing physician orders requires licensed nurses to confirm and complete instructions for new orders, but the documented events show failures in accurately maintaining and administering ordered medications for these residents.
Failure to Provide Required Daily RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide a registered nurse (RN) on duty for eight consecutive hours daily as required, affecting all 104 residents. The administrator reported that the facility does not have a stand-alone staffing policy and instead follows minimum nurse staffing guidelines, including RN coverage, and provided staffing sheets showing nurses work 12-hour shifts. Review of these staffing sheets showed that on multiple specific dates (1/3/26, 1/4/26, 1/17/26, 1/18/26, 1/31/26, and 2/1/26), there was no RN scheduled or available in the facility. The former DON stated that their last day of employment was 1/30/26 and confirmed that the facility did not always have an RN available, particularly on weekends, and that while agency nurses were used to cover open shifts, agency RNs were not always available to fill those shifts. The Long-Term Care Facility Application for Medicare and Medicaid dated 2/08/26 documented that 104 residents resided in the facility at the time of the survey, and the lack of RN coverage on the identified dates occurred despite this census.
Failure to Complete Admission Process, Manage Pain, and Act on Chest X‑Ray Results
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough admission process and to provide timely pain management for a newly admitted post‑surgical resident, as well as a separate failure to act promptly on chest X‑ray results for another resident. One resident was admitted after a left total knee arthroplasty with chronic pain, morbid obesity, and a history of motor vehicle injury, and arrived with orders for multiple pain medications including Hydrocodone, Hydromorphone (Dilaudid), Morphine, and Tizanidine. Hospital documentation indicated she required a gait belt and one‑person assist with a walker for transfers, was cognitively intact, and was being admitted for post‑surgical pain control, with controlled substance prescriptions sent in the discharge packet and Morphine next due at 9:00 p.m. Upon arrival at the facility in the early evening, the resident reported not being greeted or seen by staff for approximately two hours, not having access to a call light, and being placed in a room with a broken bed remote. When a CNA eventually responded to a call light activated by the roommate, the resident requested assistance to the bathroom. The CNA instructed her to ambulate independently with a walker, despite the resident’s report that she had not walked independently since surgery and was supposed to have staff walking beside her with a gait belt. The CNA watched her ambulate but did not assist with transfers or help her get her legs back into bed. The resident reported being in significant pain, having last received pain medication prior to leaving the hospital, and feeling unsteady and scared of falling. Later, an LPN entered the room, acknowledged knowing the resident was there but did not perform an assessment or evaluate the surgical knee. When the resident requested pain medication and repeatedly reported severe pain and that something did not feel right, the LPN stated she was unsure if any pain medication was available and left without returning with medication. The resident continued to lack ready access to a call light until she later found it on the floor and used it around midnight to again request help for uncontrolled pain. Around midnight, another LPN assessed the resident, who was in extreme pain, visibly upset, and shaking. This nurse discovered that the controlled substance prescriptions had not been faxed to the pharmacy upon admission and that the admission process, including a full admission assessment and required admission tasks, had not been completed. The prescriptions were not faxed until approximately 1:00 a.m., and the resident had not received any of her ordered pain medications since arrival. A nursing progress note documented that the prescribed pain medications were not delivered by the pharmacy, were not available through the emergency medication supply, and that the prescriptions required refaxing and a new access code. By 1:00 a.m., the resident was tearful, shaking, and stated she could not wait any longer for pain medication, requesting transfer to the emergency room, where she was treated for uncontrolled pain. The regional nurse later confirmed that staff should have greeted the resident upon arrival, ensured access to a call light, notified the pharmacy, faxed prescriptions within two hours, and completed admission assessments including pain, fall risk, transfer status, and care plan focus, and acknowledged that failure to address the resident’s pain caused undue stress and pain. In a separate incident, another resident with diagnoses including COPD with acute exacerbation and pneumonia underwent a chest X‑ray performed by a private company. The X‑ray report, received by the facility, documented opacities in the right lung base that could represent atelectasis or pneumonia. The facility’s infection control log later showed that this resident was diagnosed with pneumonia of an unknown organism and started on antibiotic therapy several days after the X‑ray. Nursing progress notes documented that nursing staff called the physician regarding the chest X‑ray results and the resident’s condition, describing the resident as extremely congested and coughing, and that the physician’s office returned the call with a new diagnosis of pneumonia and orders for a 10‑day course of antibiotics and DuoNeb treatments as needed. Despite the new orders, the medication administration record showed that the ordered antibiotic, Amoxicillin, was not actually administered until the evening of the same day the physician’s office returned the call, which was four days after the chest X‑ray results had been reported to the facility. The MAR also reflected the start of Ipratropium‑Albuterol nebulizer treatments as needed for cough, congestion, and shortness of breath beginning on the date the pneumonia diagnosis and orders were received. The DON/Infection Preventionist acknowledged that the delay in initiating antibiotic and respiratory treatment for the resident’s confirmed pneumonia resulted in prolonged infection and symptoms.
Failure to Supervise Cognitively Impaired Residents and Complete Thorough Fall Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and fall prevention for cognitively impaired residents, resulting in repeat traumatic falls and incomplete post-fall management. One resident with dementia, syncope, difficulty walking, muscle wasting, pain, and severe cognitive impairment was assessed as at risk for falls and required staff assistance for transfers. This resident experienced an unwitnessed fall in the memory care living room, where staff overheard a gasp and then found the resident on the floor with a head impact, head pain, a large hematoma, a knee skin tear, knee pain, and new back and neck pain, requiring emergency transfer and multiple CT scans. Prior to this fall, pain assessments had not been positive, but immediately afterward the resident reported high pain scores. The same resident, still identified as severely cognitively impaired and at risk for falls, later had another unwitnessed fall in the memory care dining room. Staff reported the resident repeatedly attempted to get up from a wheelchair and was redirected to sit, but at the time of the fall no staff were present because they were taking other residents to their rooms after supper. The resident attempted to self-transfer from the wheelchair, which rolled backward because the brakes were not applied, resulting in a fall to the floor, a large forehead hematoma, complaints of dizziness and pain, and another emergency transfer with multiple CT scans and new pain medication orders. The DON reported the resident lacked safety awareness and frequently attempted to self-transfer, and also reported not being aware of the presence of auto-locking brakes on the resident’s wheelchair prior to this fall, despite these behaviors having occurred for a long time. A second resident with severe cognitive impairment and total dependence for bed mobility experienced multiple falls with inadequate assessment, investigation, and monitoring. This resident had an unwitnessed fall after rolling out of bed onto a floor mat; the fall note documented confusion, a moderate pain score, and initiation of neurological checks, but the unwitnessed fall report did not identify environmental, physiological, or situational factors, and no fall risk assessment was completed before or after the fall. A subsequent fall was documented as witnessed, with the resident found partially out of bed and hanging from a side rail, but no CNA was identified and no witness statements were included, and required neurological assessments for 72 hours were only documented twice. There was no bedside side-rail assessment in the record, and after a third unwitnessed fall, safety checks were ordered but not documented as completed. The DON later confirmed deficiencies in fall investigations, assessments, neurological monitoring, care planning, and documentation, despite an existing fall prevention policy outlining required assessments, interventions, and documentation.
Failure to Manage Post‑Surgical Pain Due to Admission and Pharmacy Process Lapses
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate post‑surgical pain management for a resident admitted after a left total knee replacement. The resident had a history of chronic pain following a motor vehicle injury, morbid obesity, and left knee osteoarthritis, and had been taking Dilaudid chronically prior to surgery. Hospital discharge instructions included multiple pain medications (hydrocodone, hydromorphone/Dilaudid, morphine, and tizanidine) and directions to call the physician for severe uncontrolled pain. The hospital report indicated the resident was admitted specifically for post‑surgical pain control, was cognitively intact, required one‑person assist with a walker, and that controlled substance prescriptions were sent with the discharge packet, with morphine next due at 9:00 PM. Upon arrival at the facility in the early evening, the resident reported already experiencing significant pain. According to the resident, no nurse entered the room until approximately 9:00 PM, at which time an LPN was informed of the resident’s severe pain and request for pain medication. The LPN reportedly stated she was unsure whether any pain medication was available and, despite the resident’s repeated reports of severe pain and that something did not feel right, did not provide any intervention or return with medication. The resident stated that a subsequent call light at about 11:00 PM resulted in contact with an unidentified staff member, but again no intervention occurred, and no nurse assessed or addressed the pain during this period. Around midnight, the resident again used the call light, reporting that the pain and discomfort were no longer tolerable and expressing feelings of being disregarded and not cared for. Another LPN then assessed the resident’s pain and discovered that the controlled substance prescriptions had not been faxed to the pharmacy upon admission, so the ordered pain medications were not available in the facility or in the emergency medication supply. Nursing documentation noted that the prescriptions had to be re‑faxed and a new access code obtained, and confirmed that the resident had not received any prescribed pain medications since admission. During this time, the resident was described as in extreme pain, visibly distressed, tearful, and shaking, and ultimately requested transfer to the emergency department, where she was treated for uncontrolled pain.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours per day as required, affecting a census of 107 residents. Review of nursing staff schedules from 12/17/25 through 1/7/26 showed that on five days (12/20, 12/21, 12/26, 12/29, and 12/30/25) there was no RN coverage for at least eight consecutive hours. During an interview on 1/7/26 at 11:50 AM, the Director of Nurses (DON) confirmed that the facility did not have eight hours of RN coverage every day and acknowledged the need to hire more RNs to meet the requirement. The facility assessment dated [DATE] documented that an RN is needed every day to provide competent support and care for the resident population, and the Central Management Services 802 Matrix dated 12/23/25 confirmed the facility census of 107 residents. The deficiency centers on the facility’s failure to ensure daily RN coverage consistent with its own facility assessment and regulatory requirements, as evidenced by documented staffing schedules and the DON’s confirmation of inadequate RN staffing on the identified dates.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves multiple cognitively intact residents being left wet or soiled for extended periods, particularly during night shifts staffed by agency CNAs, in violation of their right to dignified care. One resident with frequent bowel and bladder incontinence reported that on a specific overnight, she activated her call light multiple times requesting toileting assistance, observed two agency CNAs pass her room without responding, and ultimately fell asleep with the call light on. She awoke soaked in urine on several occasions, again turned on the call light, and no staff responded; she stated she lay in a wet incontinence brief and saturated bed linens the rest of the night and felt neglected and ashamed. Day-shift CNAs later found her with fully saturated linens requiring a full bed change and total bed bath, and she reported the incident to her nurse. Day-shift CNAs corroborated a pattern of residents not being checked or changed overnight when agency CNAs worked, describing repeatedly finding residents, including this resident, with incontinence briefs “wringing wet” and bed linens showing multiple rings of dried and fresh urine and feces, indicating they had not been changed during the night. One CNA stated she could not count how many times she had found this resident’s bed saturated in the morning and that the resident was not a heavy wetter, while another CNA described following night agency staff and finding residents’ beds totally saturated, with obvious evidence that residents had not been changed on two-hour rounds. A CNA and the DON both characterized these situations as dignity issues, and the DON stated residents are to be checked every two hours on all shifts and as needed. Additional residents with no cognitive impairment and bowel and bladder incontinence reported similar experiences of not being checked or changed overnight when agency staff were on duty. One resident stated she had laid in her own incontinence for hours and believed the problem was with agency staff. Another resident, who was always incontinent and required a full-body mechanical lift, was observed by a CNA asking two CNAs to be cleaned and gotten out of bed while she had diarrhea; the CNAs told her she could not get up and that they would not change her, stating she was not finished yet. The observing CNA reported this to an RN and then returned to clean the resident herself, finding her sheets soiled and her brief full, while the resident repeatedly thanked her and said she could not stand lying in her own feces any longer. The RN later acknowledged that if CNAs told the resident she could not get up and had to remain soiled, it was not appropriate and was a dignity issue. Another resident stated that when agency staff worked nights, nobody checked on them, and that lying in urine all night made them feel horrible and like a burden.
Failure to Honor Shower Preferences and Provide Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s repeated failure to honor residents’ shower time preferences and to consistently provide scheduled showers to dependent residents, despite facility policy requiring bathing according to resident preference at least twice weekly. Multiple residents with intact cognition and no documented refusal behaviors did not receive showers as scheduled, and staff did not consistently document whether showers were offered, completed, or refused. The Director of Nursing confirmed that all residents are to receive two showers per week, that CNAs are to sign off when showers are given, and that refusals must be documented with reasons and multiple attempts; however, the records and interviews showed this was not occurring. One resident with muscle wasting, atrophy, and coordination problems, and a BIMS score indicating no cognitive impairment, was care planned as needing partial to moderate assistance with bathing and to be kept clean and dry. This resident was scheduled for showers on the night shift but requested showers on the day shift. Despite this documented preference, the resident continued to be scheduled and bathed on the night shift, with multiple weeks showing no shower sheets at all and several dates where showers were either not given, not documented as offered, or documented as declined at night without any change to the schedule. The resident and a family member both reported that showers were not being provided as supposed, and a CNA stated that this resident was among those who rarely received showers because they took a long time to complete. Another resident with epilepsy, muscle wasting, gait abnormalities, and generalized edema, and a BIMS score indicating no cognitive impairment, was scheduled for day-shift showers. On multiple documented shower dates, there was no indication that the shower was offered, done, or refused. The resident reported receiving showers but not consistently twice a week, stating that agency staff said they did not have time and that the resident often had to request showers to receive them. A third resident with primary progressive multiple sclerosis, gait abnormalities, and muscle wasting, also cognitively intact, was scheduled for showers but had gaps of a week or more with no shower documentation. This resident reported not receiving showers routinely twice a week and described being offered showers at approximately 3:00 a.m., which the resident refused as unacceptable given a known preference to sleep until mid-morning; the resident stated they generally liked showers and did not usually refuse. A fourth resident with vertebral compression fractures, restless leg syndrome, chronic pain, muscle wasting, and gait abnormalities, and a BIMS score indicating no cognitive impairment, had long periods with no shower sheets to show that showers were scheduled or provided. When showers were scheduled, documentation was often incomplete, with some entries lacking any indication of whether the shower was offered, done, or refused, and one entry noting a refusal due to pain without further documented offers. During observation, this resident was in bed with greasy, uncombed shoulder-length hair and stated needing a shower, reporting that a shower had not been offered the prior week because staff were too busy. A fifth resident with visual disturbance, cognitive communication deficit, morbid obesity, multiple pain diagnoses, muscle wasting, and difficulty walking, also cognitively intact, had multiple shower dates with no documentation of whether showers were offered, done, or refused. This resident reported receiving the first shower in two weeks the previous night, stated never refusing showers, and indicated typically receiving only one shower per week despite being told two were scheduled. Staff interviews corroborated the pattern of missed and undocumented showers. A CNA reported that three specific residents rarely received showers because they took a long time to bathe, and that the CNA tried to make up missed showers when working. Another agency CNA who frequently worked nights stated that other night staff reported resident refusals for care and showers, but that this CNA personally did not have issues with residents refusing care and was able to provide care when answering call lights, regardless of assignment. Overall, the documentation gaps, resident statements, and staff interviews demonstrate that residents’ preferences for shower timing were not honored and that scheduled showers were repeatedly not provided or properly documented, contrary to facility policy and stated expectations.
Repeated Medication Unavailability and Delayed Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely ordering, receipt, and administration of prescribed medications, including controlled substances for pain management, for multiple residents. One resident was admitted after a left total knee replacement with hospital discharge orders for several pain medications, including hydrocodone, hydromorphone (Dilaudid), morphine, and tizanidine, for chronic pain, morbid obesity, and osteoarthritis status post total knee arthroplasty. Hospital documentation indicated that controlled substance prescriptions were sent with the discharge packet and that the next morphine dose was due at 9:00 PM, with the last Dilaudid dose given at 4:00 PM prior to transfer. Nursing documentation showed that by 1:10 AM the following day, the resident’s prescribed pain medications had not been delivered by the pharmacy and were not available in the emergency supply. The LPN caring for the resident reported that the resident complained of severe left knee pain multiple times between 11:00 PM and 1:00 AM and confirmed the resident had not received any pain medication since admission. The LPN stated the pharmacy informed her they had not received the faxed controlled substance prescriptions, and she did not fax them until approximately 1:00 AM, after discovering they had only been sent with the admission packet, contrary to the facility’s admission checklist requiring orders to be faxed within two hours of arrival. Additional deficiencies were identified for another resident whose MAR documented multiple missed doses of medications due to unavailability from the pharmacy. These included missed doses of Wellbutrin XL for depression and morbid obesity, oxcarbazepine for multiple sclerosis, and estradiol cream for postmenopausal atrophic vaginitis on various dates. Each missed dose was documented as “unavailable” or “medication not available,” with corresponding administration notes confirming the lack of medication. This resident reported having a “big problem” with medications and stated that the facility was “always out of something,” indicating repeated interruptions in medication availability. A third resident, cognitively intact and documented as experiencing occasional moderate pain that frequently interfered with activities and sleep, also had missed doses of medications due to pharmacy unavailability. The MAR and administration notes showed that labetalol for atherosclerotic heart disease and duloxetine for depression were not administered because they were out of stock or there was “no medication.” The Assistant DON acknowledged that medications were not always ordered in advance as required and that delays from both nursing and pharmacy had resulted in missed doses. The pharmacist stated the pharmacy expects three to five days’ notice before medications run out, typically fills prescriptions within two days, and can provide same-day delivery for urgent needs. The DON confirmed that two residents’ medications were out of stock and acknowledged ongoing issues with timely medication delivery and ordering practices, despite facility policies requiring an effective medication distribution system and timely faxing of new admission orders to the pharmacy.
Failure to Provide Ordered Muscle Relaxant Resulting in Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a prescribed muscle relaxant for pain, Methocarbamol 750 mg three times daily, was not administered for multiple scheduled doses. The resident had diagnoses including wedge compression fracture of T9–T10 vertebra with routine healing, restless leg syndrome, chronic pain syndrome, muscle wasting and atrophy, and gait and mobility abnormalities. The resident’s MDS documented intact cognition (BIMS 15/15) and occasional, moderate pain that frequently interfered with activities and sleep. The December MAR showed repeated use of chart code 9 (Other/See Progress Notes) for the Methocarbamol doses scheduled at 6:00 a.m., 1:00 p.m., and 8:00 p.m. on multiple consecutive days, indicating the medication was not given as ordered. Progress and administration notes documented that from 12/24 through 12/27, the Methocarbamol was repeatedly noted as “on order,” “awaiting pharmacy,” “out of medication,” or “medication unavailable,” resulting in missed doses over several days. During interview, the resident reported hurting almost constantly “deep down in the muscle,” stated that the muscle relaxer was not available or not given when scheduled, and reported that even with hydrocodone, they still experienced pain, noting that the combination of medications significantly affected their comfort. The DON acknowledged unawareness of the issue until review with the surveyor, stated there had been problems with the pharmacy sending medications, and confirmed on review of the MAR that the resident had missed several Methocarbamol doses in December, characterizing this as significant and more than a single delayed dose.
Failure to Implement Droplet Isolation for Resident With Pneumonia
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control measures, specifically droplet isolation precautions, for a resident with active, symptomatic pneumonia and the resulting exposure of a roommate. One resident (R4) had a history of pneumonia treated in the hospital prior to admission and later developed congestion and an active cough while in the facility. A chest X-ray completed by a private company showed opacities in the right lung base, interpreted as possibly due to atelectasis or pneumonia, and the results were reported to the facility on 11/13/25. The facility’s Infection Control Log documented that on 11/17/25, R4 had a diagnosis of pneumonia of unknown organism and was started on antibiotic therapy, and the Medication Administration Record showed amoxicillin ordered for pneumonia for 10 days. Despite the confirmed pneumonia diagnosis and active cough, R4’s Physician Order Sheet for the relevant period did not document any order for infection control precautions, and the care plan from admission through discharge did not document that R4 was being treated for pneumonia or that isolation precautions were initiated or implemented. The MAR documented that the antibiotic was not actually administered until the evening of 11/17/25, four days after the X-ray results were reported, and continued through the morning of 11/27/25. During this time, droplet isolation precautions were never implemented from the date the X-ray confirmed pneumonia through the end of treatment, resulting in approximately 14 days of potential exposure while R4 had an active cough and was receiving treatment for pneumonia. Another resident (R3), who had no cognitive impairment per a recent MDS, reported that R4 was brought into their room as a new roommate while R4 was actively coughing all the time and had pneumonia, which staff knew about. R3 stated that no one wore gowns or masks, that R4 coughed constantly, and that R3, who spent a lot of time in bed, had to pull the curtain when in the room because they did not want to get sick. The facility’s infection precaution policy stated that transmission-based precautions, including droplet precautions, are to be used for residents known or suspected to be infected with microorganisms transmitted by droplets from coughing, and that isolation precautions may be instituted by nursing leadership or the infection preventionist without a physician’s order. The DON and Infection Control Preventionist acknowledged that R4 had an active cough with confirmed pneumonia, that droplet isolation should have been implemented immediately, and that R4 should not have been placed in the same room with R3, who did not have pneumonia.
Failure to Notify Physician of Resident’s Severe Uncontrolled Pain and Medication Unavailability
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a significant change in condition, specifically severe, uncontrolled post-surgical pain, and the unavailability of ordered pain medications. The resident had recently undergone a left total knee replacement and was admitted for post-surgical pain control with multiple prescribed pain medications, including Hydrocodone, Hydromorphone (Dilaudid), Morphine, and Tizanidine. Hospital discharge instructions directed staff to call the physician for any severe, uncontrolled pain. Upon admission, the resident was cognitively intact, required one-person assist with a walker, and had chronic pain, morbid obesity, and left knee osteoarthritis status post total knee arthroplasty. The hospital report indicated that controlled substance prescriptions were sent with the discharge packet and that the resident had last received Dilaudid at 4:00 p.m. prior to transfer. According to nursing documentation, by 1:10 a.m. the resident’s prescribed pain medications had not been delivered by the pharmacy and were not available in the facility’s emergency medication supply. At approximately 1:00 a.m., the resident was tearful, shaking, and stated she could not wait any longer for pain medication, requesting transfer to the emergency room. The progress note did not document any physician notification. The LPN caring for the resident overnight confirmed that the resident complained of severe left knee pain multiple times between 11:00 p.m. and 1:00 a.m., had not received any pain medication since admission, and that the LPN did not notify a physician about the severe pain, the lack of available ordered pain medications, or the resident’s request to go to the emergency room because she was unsure who the resident’s physician was. The Regional Nurse confirmed that nursing staff should have notified the physician when the resident’s pain became severe, when ordered pain medications were unavailable, and when the resident was transferred to the hospital. The facility’s policy required physician notification for significant changes in condition and when a decision is made to transfer a resident from the facility.
Failure to Recognize and Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The facility failed to recognize and report an allegation of abuse to the State Agency after a resident complained about the conduct of a CNA. The grievance tracking log for November 2025 shows that the resident filed a grievance on 11/06/25, but the log contains no additional information about the nature of the grievance. A Grievance Concern/Compliment Form dated the same day documents that the Housekeeper/Laundry Supervisor received the report and recorded that the resident stated a CNA, described as a heavier-set girl of a specified race, threw clothes at the resident and told the resident to get dressed and into the wheelchair independently. The resident’s MDS showed a Brief Interview of Mental Status score of 13/15, indicating no cognitive impairment. Despite this, the Administrator/Abuse Prevention Coordinator did not report the grievance to the Illinois Department of Public Health, stating he considered it a customer service issue rather than abuse at the time. In an interview, the resident recounted that the CNA tossed clothes to her, told her to dress herself, and that she then had to get into her wheelchair on her own. The resident reported feeling upset and described the CNA as rude and in a hurry, and stated that no one deserves to be rushed or treated rudely. The Housekeeper Supervisor later stated that the resident appeared anxious and somewhat agitated, with a facial expression suggesting she was holding back tears, and that the resident reported the CNA had thrown her clothes and told her to dress and get into her wheelchair by herself. The Housekeeper Supervisor also stated that this concern was reported immediately to the Administrator/Abuse Prevention Coordinator and that the resident stated she felt abused. The facility’s Abuse Prevention and Reporting policy, revised 10/24/22, requires that any allegation of abuse be reported to the Illinois Department of Public Health immediately, but no later than two hours after the allegation, or within 24 hours for incidents not involving abuse and not resulting in serious bodily injury. The Administrator acknowledged that the resident’s grievance should have been reported as an abuse allegation in accordance with this policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours per day, as required. Review of Nursing Hall Assignment Sheets from 8/27/25 through 9/15/25 revealed that on nine separate days, there was no RN coverage for the required duration. This was confirmed by the facility administrator, who acknowledged the absence of RN staffing on those days. The facility maintained an average daily census of 104 residents during this period, as documented in the Bed Management sheet.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide multiple scheduled showers for dependent residents, as required by its own policy, which states that residents should be offered a shower, tub bath, or bed/sponge bath at least two times per week or according to their preference. Documentation in the electronic medical records for three residents revealed missed showers without any record of showers, baths, or refusals for several scheduled dates. Specifically, one resident with diagnoses including dementia, Parkinson's disease, and a pressure ulcer was scheduled for showers twice weekly but only received five showers over a 30-day period, with no documentation for other scheduled dates. Another resident with chronic kidney disease, muscle atrophy, sepsis, gangrene, and diabetes was also scheduled for twice-weekly showers but only received three showers and had two refusals documented, with no other entries for the remaining dates. A third resident with dementia, delusional disorder, and depression received only two showers and had two refusals documented, with no other records for the rest of the scheduled showers. Interviews with the facility's administrator and director of nursing confirmed that the expectation is for residents to receive two showers per week and for staff to document all showers given or refused in the electronic medical record. Both leaders acknowledged that staff are required to document when a shower is given or refused, and if a shower is refused, the nurse should be notified to reapproach the resident and address any barriers. The lack of documentation and missed showers for these dependent residents represents a failure to follow facility policy and ensure proper hygiene and dignity for residents unable to perform activities of daily living independently.
Failure to Complete and Address Repeated Refusals of Wound Care Treatments
Penalty
Summary
The facility failed to complete multiple wound dressing treatments and did not address a resident's repeated refusals for wound care as required by physician orders. According to the facility's policy, dressing changes should be performed in accordance with physician orders and documented in the Treatment Administration Record (TAR), with staff initialing the electronic TAR after each administration. For one resident diagnosed with dementia, delusional disorder, depression, need for assistance with personal care, and malignant neoplasm of the right breast, there was a physician order for daily wound treatment to the right breast. The resident's care plan also specified that staff were to perform treatments per physician order for a cancer ulcer under the right breast. Record review revealed that, over a period of several months, there were multiple instances where wound treatments were not completed and several occasions where the resident refused treatment. Specifically, the TARs documented missed and refused treatments across July, August, and September, with a pattern of both non-completion and repeated refusals. The Director of Nurses confirmed that staff are expected to complete wound care as ordered and to notify the physician and document in the electronic medical record if treatments are not completed or if there are repeated refusals.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. One resident, who had a documented history of physical and verbal aggression, psychiatric and cognitive impairments, and was not cognitively intact, made physical contact with another resident's upper thigh while the second resident was lying in the first resident's bed. Staff interviews confirmed that the aggressive resident frequently attempted to grab or reach for other residents and had previously been physical with others. The care plan for the aggressive resident noted ongoing issues with ineffective coping and aggression related to cognitive impairment. Despite these known behaviors and risks, the facility did not prevent the incident of physical abuse, as documented in the facility's abuse report and confirmed by staff and administrative interviews.
Failure to Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a fall investigation, develop a root cause, and implement relevant fall interventions for one resident who was at high risk for falls. The resident had multiple diagnoses, including cellulitis of the right lower limb, chronic pain, lack of coordination, and required assistance with personal care. The resident was documented as not cognitively intact and required supervision or touching assistance with walking. The care plan identified impaired cognitive function and high fall risk, with interventions to cue, reorient, and supervise as needed. Despite these risk factors, the facility did not report the resident's fall in a timely manner, and the incident was only recognized after a coroner's request from the hospital following the resident's death. Interviews revealed confusion and lack of communication among facility staff regarding the reporting and investigation of the fall. The Administrator stated that the fall was not reported until after the coroner's inquest, and the DON and ADON each believed the other was responsible for reporting and follow-up. The facility's policy required that all incidents or accidents be reported, assessed, and investigated by nursing staff and reviewed by the Administrator and DON, but this process was not followed in this case. The failure to promptly report, investigate, and address the fall resulted in a lack of timely interventions for the resident.
Failure to Accurately Document and Maintain Resident Records
Penalty
Summary
The facility failed to accurately document and maintain resident records in accordance with accepted professional standards for five residents. An audit of documentation revealed a total of 40 instances of mis-documentation related to Activities of Daily Living (ADL) over a 30-day period, with individual residents experiencing between two and sixteen occurrences each. The mis-documentation included false charting, such as documenting that baths were provided when they were not actually given. These findings were supported by a review of the facility's Employee Disciplinary Form and interviews with facility staff.
Failure to Provide Consistent Quality Care Due to Staffing and Supply Issues
Penalty
Summary
The facility failed to provide consistent quality care and treatment according to physician orders, resident preferences, and goals for five of eight residents reviewed. Multiple residents and their family members reported significant delays in call light responses, missed scheduled showers, and incomplete two-hour checks. Facility records, including grievance logs and resident council minutes from March to May 2025, documented ongoing concerns about inadequate staffing, particularly the use of agency CNAs who did not complete assigned tasks, were frequently absent, or displayed unprofessional behavior such as using phones while on duty and being loud at night. Several residents with complex medical needs, including those with hemiplegia, COPD, diabetes, heart failure, and those on anticoagulant therapy, experienced lapses in care. For example, one resident was unable to find staff to assist with bedtime care, leading her daughter to intervene and search the facility, only to find staff unavailable or sleeping. Other residents reported waiting over 30 minutes for call lights to be answered, and delays in receiving essential blood work due to the facility lacking necessary PT/INR testing supplies. These delays resulted in late administration of critical lab tests and medication adjustments for residents on blood thinners. Staff interviews confirmed the issues, with LPNs and the DON acknowledging problems with agency staff reliability and accountability, as well as the impact on resident care quality. The DON confirmed ongoing complaints about missed showers, delayed call light responses, and incomplete care tasks. The facility assessment stated that supplies and equipment would be provided in a timely manner, but this was not consistently achieved, as evidenced by the lack of PT/INR test strips and the need to send blood samples to an outside lab, causing further delays in care.
Failure to Maintain Adequate Supplies of Incontinence Briefs and Linens
Penalty
Summary
The facility failed to provide adequate supplies of incontinence briefs and linens, including washcloths, to meet the needs and preferences of several residents. Multiple residents reported that the facility ran out of their appropriate size briefs, resulting in the use of smaller, uncomfortable, or unusable alternatives. Staff interviews confirmed that the facility was out of various sizes of briefs over a weekend, and a rush order was placed for additional supplies. The Director of Nursing acknowledged awareness of low supplies but was unable to purchase more due to a negative balance on the corporate credit card, and the regular supply person was unavailable. The facility administrator confirmed difficulties in obtaining supplies and admitted that a supply management system was lacking. Additionally, residents and staff reported ongoing shortages of washcloths, particularly after the facility discontinued the use of incontinence wipes. Resident council meeting minutes documented concerns about linen shortages, and several CNAs confirmed frequent shortages of washcloths, with some resorting to using bath towels as substitutes. Observations of linen carts and laundry areas corroborated the lack of available washcloths across multiple hallways. The laundry aide confirmed that CNAs often came to the laundry room seeking washcloths when supplies were depleted, and that this had been an ongoing issue.
Failure to Provide Ordered Pressure Ulcer Care and Accurate Documentation
Penalty
Summary
The facility failed to provide ordered dressing changes and did not accurately document the progression of pressure wounds for three out of four residents reviewed for pressure injuries. For one resident, a wound initially identified as a skin tear was later documented by the wound physician as a stage three wound after debridement, but the wound nurse was unaware of this change and continued to treat it as a skin tear. Additionally, the treatment administration record showed that a prescribed dressing change was not completed on a specific date. Another resident was admitted with a right heel pressure wound and had physician orders for daily wound care, but the treatment administration record indicated that dressing changes were not completed on three consecutive days. A third resident had physician orders for twice-daily dressing changes to a left hip wound, but the treatment administration record documented that the evening dressing change was not completed on multiple dates. The wound nurse confirmed that if a dressing change was not documented, it was not performed.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for two of three residents reviewed for significant medication errors. According to the facility's policy, medications are to be administered within 60 minutes of scheduled times and documented on the Medication Administration Record (MAR). For one resident with diagnoses including epilepsy, hypertension, and venous thrombosis, multiple prescribed medications such as Keppra, Oxcarbazepine, Chlorthalidone, Eliquis, and Amlodipine were not administered on several occasions as documented in the MAR. The resident reported that missed doses often occurred when agency nurses were on duty. Another resident with diagnoses of diabetes, ocular hypertension, primary hypertension, peripheral vascular disease, and heart disease also experienced missed doses of several critical medications, including Clopidogrel, Glimepiride, Hydrochlorothiazide, Lisinopril, Metoprolol Succinate, Metformin, Cephalexin, and Pregabaline, as recorded in the MAR. The DON confirmed unawareness of the reasons for these missed doses and acknowledged that medications are expected to be given as ordered.
Failure to Ensure Resident Dignity During Medication Administration
Penalty
Summary
A deficiency occurred when a resident, who is cognitively intact and has diagnoses including epilepsy, primary hypertension, and venous thrombosis with embolism, did not receive her prescribed anti-seizure medications (Keppra and Oxcarbazepine) on time. The resident reported that on a Sunday evening, she was supposed to receive her medications between 4:00 PM and 8:00 PM but did not receive them until 1:00 AM. When she inquired about her seizure medications, the agency nurse on duty responded curtly, stating, 'Well, I guess you will just have to have a seizure.' The LPN involved acknowledged being overwhelmed that night and admitted to being curt with the resident, confirming that the medications were administered late. The Director of Nursing stated that such a response was unacceptable and harsh. The resident expressed feeling disrespected, unprofessional treatment, and a loss of dignity as a result of the nurse's comment and the delay in receiving her medications.
Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to administer medications according to physician orders for two of three residents reviewed for medication administration. Facility policy requires medications to be administered as prescribed and within 60 minutes of scheduled times, with documentation on the Medication Administration Record (MAR). For one resident, multiple medications including Amiloride, Celexa, Cranberry tablets, Fiber-Lax, and Famotidine were not administered on several specified dates, as evidenced by gaps in the MAR. The resident, who was documented as cognitively intact, reported that missed doses typically occurred in the evening and often involved agency nurses unfamiliar to her. For another resident, the MAR showed that several daily medications, such as Aspirin, CoQ-10, Multivitamin, Fenofibrate, Rosuvastatin, and Myrbetriq, were not administered on multiple dates. The Director of Nursing was unable to provide an explanation for the missed doses and acknowledged that if medications were not documented as given, they were not administered. The Director also stated that medications are expected to be given as ordered and recognized that failure to do so can be harmful to residents.
Unqualified Director of Activities
Penalty
Summary
The facility failed to provide the services of a clinically qualified Director of Activities, which has the potential to affect all 77 residents residing in the facility. On February 18, 2025, the individual identified as the Director of Activities, V5, stated that they are responsible for managing all aspects of the activity department, including completing and implementing the facility activity calendar and scheduling staff. However, V5 admitted to not being certified and expressed uncertainty about when they would enroll in the necessary certification course. Despite actively managing activity personnel and directing staff, V5's lack of certification was confirmed by another staff member, V1, on February 19, 2025.
Failure to Provide Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide and implement activities to meet the interests and needs of residents in the Memory Care Unit, affecting five residents. Observations revealed that residents were left sitting at tables with no group activities or individual engagement, and their activity participation was not documented. The Memory Care Unit lacked an activity calendar, and the Memory Care Unit Activity Binder had no documentation for the residents for the month of January 2025. Residents had various diagnoses, including dementia and anxiety, and their care plans indicated the importance of participating in activities. For instance, one resident's care plan emphasized participation in group activities and outdoor activities, while another resident's care plan highlighted the importance of reading, word searches, and social groups. Despite these documented preferences, residents were not engaged in meaningful activities, and their care plans were not followed. Staff interviews revealed that the Memory Care Unit had not had a dedicated activity person since December, and the staff were unable to conduct group activities due to staffing issues. The Memory Care Specialists, who were also CNAs, were responsible for both resident care and activities, leading to insufficient time to engage residents in activities or document their participation. The facility's regional administrator and enrichment specialist acknowledged the lack of activities and documentation, indicating a systemic issue in meeting the residents' needs for mental stimulation and engagement.
Failure to Implement Post-Fall Interventions and Conduct Thorough Investigations
Penalty
Summary
The facility failed to complete thorough investigations and implement post-fall interventions for three residents who experienced falls. Resident 26 had multiple unwitnessed falls resulting in injuries, including a laceration above the left eye and a head laceration requiring sutures and staples. Despite these incidents, the resident's care plan was not updated with new fall interventions after the falls on September 18 and October 13. The Director of Nursing confirmed that no new interventions were initiated following these falls. Resident 16, diagnosed with difficulty walking and unsteadiness, experienced a fall on November 22, resulting in a knee laceration requiring sutures. The care plan for this resident was not updated with new interventions following the fall, and there was no documentation of a thorough fall investigation or root cause analysis. The Director of Nursing and the Administrator confirmed the lack of new interventions and the absence of a root cause analysis. Resident 15 reported a fall involving an aide in mid-September, leading to a refracture of the left femur head. The resident's care plan did not document new interventions post-fall, and there was no documentation of post-fall assessments or investigations. The facility failed to provide an investigation for the fall on August 15, and the Administrator denied knowledge of any fall involving staff after that date.
Failure to Resolve Resident Grievances on CNA Phone Usage
Penalty
Summary
The facility failed to ensure that grievances raised by the Resident Council were resolved in a timely manner, affecting all 90 residents. The facility's Grievance Policy, revised on June 1, 2022, states that residents have the right to voice grievances and that these should be addressed promptly. However, Resident Council Minutes from January to November 2024 consistently document unresolved concerns about certified nursing assistants (CNAs) using cell phones and ear buds during resident care, being loud in hallways, and displaying rude attitudes. These issues were repeatedly brought up in Resident Council meetings, indicating a lack of timely resolution by the facility. Interviews conducted on December 3, 2024, with two residents revealed ongoing dissatisfaction with the facility's handling of these grievances. One resident expressed frustration that CNAs were often on their phones and wearing ear buds while providing care, and felt that the facility was not addressing the problem. Another resident noted that CNAs frequently used their phones once management left the building, and despite raising these concerns repeatedly, the situation had not improved. The facility administrator acknowledged awareness of the cell phone issues and mentioned plans to implement management staying later to monitor staff phone usage, but this does not address the deficiency itself.
Failure to Verify Employee Eligibility Prior to Employment
Penalty
Summary
The facility failed to document receiving registry verification that several employees met eligibility requirements to work in the healthcare facility prior to their start dates. This deficiency was identified during a review of employee files for Certified Nursing Assistants (CNAs) and other staff members. The review revealed that the Illinois Health Care Worker registry verification was not obtained for employees V32, V33, V34, V35, V36, and V37 before they began their employment. The registry checks were only added to the employee files on 12/3/24, despite their employment starting in November 2023. The Human Resource Manager, V13, who was new to the position, was unable to locate any documented evidence of registry verification for the new employees. This oversight has the potential to affect all 90 residents residing in the facility, as the eligibility of the staff to work in the healthcare setting was not confirmed prior to their employment. The facility's failure to ensure proper documentation and verification of employee eligibility highlights a significant lapse in compliance with regulatory requirements.
Inaccurate Facility Assessment Omits Critical Equipment and Medications
Penalty
Summary
The facility failed to conduct and document an accurate facility-wide assessment, which has the potential to affect all 90 residents. The assessment did not include essential equipment and medications necessary for resident care. Specifically, the assessment omitted the listing of sit-to-stand or sling-type mechanical lifts, despite 18 residents currently using these lifts for mobility. The Assistant Director of Nursing confirmed that all residents might need mechanical lifts in the event of a fall. Additionally, the assessment failed to list narcotic medications or opioids, even though a resident's Medication Administration Record indicated a current order for hydrocodone-acetaminophen. The Assistant Director of Nursing and the Administrator verified that narcotic pain medications are used for multiple residents, yet these were not included in the facility assessment.
Infection Control Deficiencies in Laundry and COVID-19 Outbreak Management
Penalty
Summary
The facility failed to maintain proper infection prevention procedures in its laundry services, potentially affecting all 90 residents. An observation revealed that a laundry aide, identified as V9, did not wear appropriate personal protective equipment (PPE) such as a gown while sorting soiled linens. V9's personal clothing came into contact with soiled linens, and she did not wash her hands after handling soiled items. Despite having received training on PPE use and handwashing, V9 did not adhere to these protocols, as confirmed by the facility administrator. The facility also failed to notify visitors in a timely manner about a COVID-19 outbreak and did not ensure that staff wore appropriate PPE. Upon entering the facility, there was no signage indicating an outbreak or PPE requirements. Staff, including the receptionist and maintenance personnel, were observed wearing only procedure masks. The facility administrator confirmed the outbreak but had not posted signage until later. Observations on the 200 wing showed improper PPE use, such as a housekeeper wearing a procedure mask instead of an N95 mask and not using eye protection while cleaning isolation rooms. Additionally, the facility did not notify the local health department of the outbreak. Staff were observed wearing standard procedure masks instead of N95 masks in patient care areas, and direct care staff entered isolation rooms without proper PPE. The facility's communication regarding the outbreak was inadequate, as a text message sent to staff did not specify recipients or confirm receipt. The facility had not yet contacted the local health department about the outbreak, despite having multiple residents test positive for COVID-19.
Failure to Document COVID-19 Vaccine Education and Offering for Staff
Penalty
Summary
The facility failed to document the education, offering, and consent or declination of COVID-19 vaccines for staff members, which has the potential to affect all 90 residents residing in the facility. During a review of staff files, including those of LPNs, CNAs, and a Resident Aide, no documented evidence of these actions was found. The Human Resource Manager, who was new to the position, was unable to locate any documentation related to the COVID-19 vaccine education and offering for staff. Additionally, the staff confirmed the absence of such documentation, indicating a lapse in the facility's record-keeping practices regarding COVID-19 vaccination protocols for staff.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to implement accurate and complete care plans for four residents, leading to deficiencies in addressing their medical needs. One resident with multiple pressure ulcers and a history of falls did not have these conditions documented in their care plan, nor were their medications for depression, anxiety, and anticoagulation included. Another resident with heart failure and chronic obstructive pulmonary disease was observed using oxygen therapy, yet their care plan lacked any mention of this treatment. Additionally, a resident admitted for a vascular disorder of the intestine had a care plan that incorrectly documented a knee replacement as the reason for admission, omitting the actual medical condition. Furthermore, a resident with Amyotrophic Lateral Sclerosis expressed difficulty in communication, which was not addressed in their care plan, despite being able to speak softly and deliberately. These omissions indicate a failure to develop comprehensive, person-centered care plans as per the facility's policy.
Failure to Document and Administer Vaccines
Penalty
Summary
The facility failed to properly assess and document the administration of pneumococcal and influenza vaccines for four residents. For Resident 14, the medical record lacked a completed Influenza Education and consent/declination form, and the Medication Administration Record (MAR) did not document the administration of the influenza or pneumococcal vaccines, despite the face sheet indicating the influenza vaccine was administered. Resident 43's records showed a completed influenza consent form but an incomplete pneumococcal consent form, with no documentation of vaccine administration in the MAR, although the face sheet noted the influenza vaccine was given. Resident 26 had a completed influenza consent form but an incomplete pneumococcal consent form, with the MAR lacking documentation of vaccine administration, despite the face sheet indicating the influenza vaccine was administered. Resident 54's records included an incomplete influenza consent form and no pneumococcal consent form, with the MAR not documenting vaccine administration, although the face sheet noted the influenza vaccine was given. The facility's failure to ensure proper documentation and administration of vaccines was confirmed by a staff member, who stated that undated consents are not valid and lack of documentation indicates vaccines were not administered.
Failure to Submit MDS Timely for a Resident
Penalty
Summary
The facility failed to submit the Minimum Data Set (MDS) in a timely manner for one resident, identified as R74, out of 18 residents reviewed for MDS in a sample list of 43. The Final Validation Report printed on December 4, 2024, documented that R74's MDS target date of May 2, 2024, was late, with the Care Areas Assessment (CAA) being more than 13 days after the entry date. Additionally, R74's MDS target date of July 24, 2024, was also completed late, with the CAA being more than 14 days after the assessment reference date. On December 4, 2024, at 8:56 AM, the Care Plan Coordinator and the Corporate Care Plan Consultant verified that the assessments and care plans for R74 dated May 2, 2024, and July 24, 2024, were late. The facility's Care Plan Policy, revised on November 28, 2019, states that the comprehensive care plan should be developed within seven days after the completion of the comprehensive MDS assessment as outlined in the resident assessment (RAI) guidelines.
Inaccurate Resident Assessment Due to MDS Error
Penalty
Summary
The facility failed to accurately complete a comprehensive assessment for a resident. The Minimum Data Set (MDS) for the resident documented the use of an anticoagulant, but the clinical physician orders did not include any such medication. Upon review, a staff member confirmed that the resident was not on an anticoagulant and acknowledged that the MDS was incorrectly coded.
Failure to Conduct Level II PASARR for Residents with Mental Disorders
Penalty
Summary
The facility failed to refer residents with newly diagnosed serious mental disorders for a level II PASARR resident review upon a significant change in status assessment. Two residents, identified as R6 and R14, were affected by this deficiency. R6 was diagnosed with unspecified psychosis and prescribed Seroquel, yet their Interagency Certification of Screening Results did not indicate a reasonable basis to suspect a mental illness. Similarly, R14 was diagnosed with paranoid schizophrenia and also prescribed Seroquel, but their screening results did not document a reasonable basis to suspect a mental illness. Interviews with the Director of Nurses and the Administrator revealed that the social service director was responsible for screenings, and it was confirmed that neither resident had a level II screening in their medical record.
Insulin Administration Timing Deficiency
Penalty
Summary
The facility failed to administer insulin according to the manufacturer's directions and professional standards of practice for three residents. Resident 25 had an active physician's order for Novolog Flexpen U100 to be administered subcutaneously per sliding scale before meals. The manufacturer's instructions indicate that Novolog should be taken 5 to 10 minutes before eating. However, on December 4, 2024, the insulin was administered at 11:04 AM, but lunch was not served until about 12:00 PM, leaving a significant gap between administration and meal consumption. Similarly, Resident 45 had an order for Admelog SoloStar U-100 Insulin to be administered with meals, but the insulin was given at 11:02 AM, well before lunch was served. Resident 47 also had an order for Admelog SoloStar U-100 Insulin to be administered per sliding scale before meals and at bedtime, but the insulin was administered at 11:02 AM, again before lunch was served. The manufacturer's instructions for Lispro insulin specify administration within 15 minutes before a meal or immediately after. The Licensed Practical Nurse confirmed that no nourishment was provided to these residents between receiving insulin and being served lunch, which was verified by the Administrator the following day.
Failure to Address Communication Needs for Resident with ALS
Penalty
Summary
The facility failed to provide an effective communication program for a resident, identified as R40, who has Amyotrophic Lateral Sclerosis, Dysphasia, and Anxiety Disorder. Despite being cognitively intact and able to speak, albeit softly and deliberately, R40 expressed that staff do not take the time to listen, assuming he cannot communicate. An LPN, who frequently works at the facility, confirmed that there is no plan in place to address R40's communication needs. Additionally, R40's care plan, updated in October, did not address his communication issues, which is contrary to the facility's policy requiring comprehensive, person-centered care plans that meet residents' needs as identified in their assessments.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to properly assess and implement necessary interventions and treatments for pressure ulcers for two residents. Resident R181, who was cognitively intact and not initially at risk for pressure ulcers, developed a stage II pressure ulcer on the coccyx. Despite having a treatment order for the ulcer, R181 was observed without a pressure-relieving mattress, and the care plan was not updated to reflect the current pressure ulcer or any changes in skin risk status. The facility's policy required assessments for special need items, which were not conducted for R181. Resident R15 was observed in bed without sheets, lying directly on the mattress, with undated dressings on multiple wounds, including a stage 2 pressure ulcer on the left heel. The air mattress had an error light flashing, and R15 reported not moving all day. The facility's treatment record showed 13 missing treatment administrations for R15, and the care plan did not document current pressure ulcers or interventions, despite hospital discharge orders for pressure ulcer treatments. These deficiencies indicate a lack of adherence to the facility's pressure ulcer prevention and treatment policies.
Failure to Date and Label Oxygen Equipment
Penalty
Summary
The facility failed to properly date and label humidifier bottles and oxygen tubing for three residents who required respiratory services. The facility's Oxygen Policy and Procedure mandates that oxygen setup, including cannula, mask, and tubing, must be exchanged every seven days and documented accordingly. However, observations revealed that the oxygen equipment for the residents was not dated, and in some cases, the humidifier bottles were empty or not attached, indicating a lack of adherence to the policy. For one resident, the oxygen concentrator was running via a nasal cannula, but the humidifier bottle was empty and undated. Another resident's oxygen concentrator was observed without a humidifier bottle, and the nasal cannula was undated. A third resident was seen with an undated humidification bottle and oxygen tubing, both in their room and while walking in the hallway. These observations were confirmed by staff interviews, which acknowledged that the facility's policy was not being followed.
Failure to Monitor Bowel Function in Resident on Opioid Medication
Penalty
Summary
The facility failed to monitor the bowel function of a resident receiving opioid medication, specifically hydrocodone-acetaminophen, as part of their drug regimen. The resident had a current order for this medication to be taken orally every 8 hours as needed and received it four times over a six-day period. However, there was no documentation to support that the resident's bowel function was being monitored, despite the known risk of constipation associated with opioid use. The resident's care plan, reviewed in October, did not include interventions for monitoring bowel movements related to opioid use. Additionally, a progress note from October indicated that the resident had not had a bowel movement in three days. The Director of Nursing confirmed that the facility lacked a system for monitoring bowel function in residents using narcotic medications, and the Administrator verified the absence of a specific policy for narcotic medication monitoring.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to obtain consent, assess, and monitor residents receiving psychotropic medications, and did not document attempts to utilize non-pharmacological interventions for two residents. For one resident, active physician's orders included multiple psychotropic medications, but the electronic medical record lacked assessments, behavior tracking, or documentation of non-pharmacological interventions. The Director of Nursing confirmed the absence of these assessments and interventions. For another resident, a registered nurse reported no specific behavior tracking, and the resident's point of care task tracking sheet showed incomplete documentation of behaviors. The resident's care plan did not document the use of anti-depressant and anti-anxiety medications or interventions for nursing care. Additionally, there was no documented attempt at gradual dose reduction for the resident's medications, and the consent on file for lorazepam was outdated.
Failure to Conduct Timely A1C Tests for Diabetic Resident
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident diagnosed with type two diabetes mellitus. The resident had physician orders for A1C tests to be conducted on specific dates in February and August 2024. However, the medical records only showed an A1C test result from October 2024, with no documentation of the tests being conducted on the ordered dates. Interviews with the Director of Therapy and the Director of Nursing confirmed that the A1C tests were not completed as ordered, indicating a lapse in the facility's process to ensure laboratory tests are conducted as per physician orders.
Failure to Update Care Plans After Falls and Pressure Ulcers
Penalty
Summary
The facility failed to revise care plans following significant changes in the condition of three residents, which included falls with injury and the development of new pressure ulcers. For one resident, identified as R181, the care plan was not updated to reflect a new stage II pressure ulcer on the coccyx, despite treatment being documented in the Treatment Administration Record. The resident was observed to be confused and disoriented, and was not on a pressure-relieving mattress, which was a concern given the resident's increased time spent in bed. Another resident, R15, experienced multiple falls resulting in a refracture and subsequent surgery, yet the care plan did not document these falls, the revision surgery, or necessary post-operative precautions. Additionally, the care plan lacked documentation on pressure ulcers or preventative measures, despite hospital discharge orders indicating the need for such treatment. Similarly, R26 experienced multiple unwitnessed falls with injuries, but the care plan was not updated with fall interventions. The family member of R26 expressed concern over the lack of discussion and preventive measures regarding the falls during care plan meetings. The Director of Nursing confirmed that no fall interventions were initiated after R26's falls, highlighting a lapse in care plan updates and interventions.
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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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