Goldwater Care Danville
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, Illinois.
- Location
- 620 Warrington Avenue, Danville, Illinois 61832
- CMS Provider Number
- 145183
- Inspections on file
- 38
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Goldwater Care Danville during CMS and state inspections, most recent first.
Surveyors found that multiple residents did not receive care according to physician orders and facility policies. A resident with long-standing type 1 DM was admitted with hospital orders for basal and sliding-scale insulin and frequent BG monitoring, but the sliding-scale order was not transcribed, BG checks were inconsistent, the continuous glucose monitor was compromised by BP measurements on the sensor arm, and staff did not consistently notify the provider when insulin was held, the device failed, or BG checks were refused, contributing to rehospitalization for DKA. Another resident with DM had numerous doses of both basal and short-acting insulin held over several months without any documented MD notification, despite no active parameters to hold the short-acting insulin. A cognitively impaired resident sustained an unwitnessed fall, later developed severe back pain and tearfulness, and had delayed diagnostic evaluation and pain management because staff did not promptly report the new pain to the provider or notify family until hospital transfer; neurological checks after this fall were documented with identical vital signs at each interval, indicating they were not properly performed. In a separate fall involving a resident with DM, prior intracranial hemorrhage, and anticoagulant use, staff did not obtain a post-fall BG or initiate neuro checks, contrary to the care plan and facility policies.
Surveyors found that the facility failed to implement and care plan fall interventions, accurately complete fall risk assessments, and thoroughly investigate falls for three residents. One cognitively intact resident with documented fall risk and ordered bed and chair alarms had two self‑transfer falls, inaccurate fall risk assessments that understated both ambulation status and high‑risk medications, and post‑fall investigations that omitted when the resident was last observed or toileted; the resident was later observed in a recliner without an alarm, and a CNA was unsure about alarm requirements. A second resident with severe cognitive impairment and total incontinence sustained a bathroom fall with an L1 fracture, with no documentation clarifying whether staff had transferred and left the resident unattended, and the care plan did not reflect the chair alarm use documented in nursing notes and staff interviews. A third resident with moderate cognitive impairment and total incontinence had two falls, inaccurate fall risk assessments that did not match the high‑risk medications on the MAR, and fall investigations that lacked documentation of when the resident was last checked or toileted.
A resident with a recent subdural and subarachnoid hemorrhage and a care plan noting bleeding risk related to anticoagulant use was readmitted from the hospital with discharge instructions from neurosurgery to hold all antiplatelet/anticoagulant medications, and Eliquis was not listed among active discharge medications. Facility policy required review of the hospital discharge summary, clarification of orders with the physician, and discontinuation of previous orders when medication orders changed, but staff failed to discontinue the prior Eliquis order. As a result, Eliquis 5 mg was administered on multiple occasions over two months, with intermittent holds and resumptions due to an initially missed order and a time-limited hold entry, leading to repeated significant medication errors.
Multiple failures in pressure ulcer prevention, assessment, and infection control were identified, including lack of timely repositioning, incomplete skin assessments, and failure to update care plans. Residents developed multiple facility-acquired pressure ulcers, some of which became infected. Staff did not consistently follow physician orders, failed to provide wound supplements, and did not prevent cross-contamination during wound care. Infection control breaches and delayed interventions contributed to worsening wounds and infections.
The facility did not maintain adequate CNA staffing levels as outlined in its own staffing plan, resulting in frequent short-staffing across multiple shifts. This led to delays in call light responses, missed showers, and challenges in repositioning and transferring residents, including those with significant care needs such as stage three or four pressure ulcers. Staff interviews and facility records confirmed that the deficiency affected all residents, especially those requiring two-person assistance.
A medication administration observation revealed a 10.7% error rate when a RN administered incorrect doses of Sertraline, Levothyroxine, and Calcium + Vitamin D3 to a resident. The errors included giving multiple doses of Levothyroxine beyond the prescribed amount, as documented in the MAR and physician orders. The nurse acknowledged the mistakes, and facility policy requiring triple checks of the five rights was not effectively followed.
Staff failed to follow contact isolation precautions for a resident with multiple infected pressure ulcers and severe cognitive impairment. An LPN entered the room without PPE, handled surfaces and supplies with bare hands, and did not perform hand hygiene, resulting in contamination of wound care materials later used on the resident. The DON confirmed that these actions were not in accordance with facility policy.
The facility did not report or investigate allegations of neglect and injuries of unknown origin for three residents, including cases involving derogatory staff remarks, unexplained facial bruising, and unreported injuries. Required notifications to the administrator and state survey agency were not made, and investigations were incomplete or not conducted, despite residents having cognitive impairments and complex medical histories.
Three residents who experienced falls or head injuries did not receive neurological assessments as ordered by physicians or as required by facility policy. In one case, a resident did not receive a follow-up x-ray or orthopedic consult as ordered, and in two other cases, neurological checks were either incomplete or not documented after injuries. Staff, including the DON and LPN, confirmed the missing documentation and incomplete assessments.
Staff failed to keep a resident's personal and medical information confidential, openly discussing the individual's alleged history of abuse in hallways, at the nurses' station, and in offices with open doors. Multiple staff, including CNAs, an LPN, and activity aides, participated in or overheard these conversations, which violated the facility's policy on resident privacy and confidentiality.
A resident with moderate cognitive impairment and a recent history of blood disorder and possible cancer was found with unexplained facial and arm bruising. Although an LPN was aware and notified the family, the DON and administrator were not informed, no investigation was conducted, and the physician was not notified. The incident was not documented in the medical record or incident log, in violation of facility policy for injuries of unknown source.
Two residents with cognitive impairments and unexplained facial bruising did not receive thorough investigations into their injuries, as required by facility policy. Staff either conducted minimal interviews or failed to document and report the injuries, and the DON and administrator were not always aware of the incidents. The facility did not follow its own procedures for investigating and documenting injuries of unknown origin.
A resident with severe cognitive impairment who requires supervision for ambulation fell while attempting to get dressed without staff assistance, resulting in a head injury and arm splint. The facility's fall investigation did not determine the root cause, lacked documentation on footwear and walker use, and did not include a full interview with the CNA who witnessed the event, leading to incomplete post-fall interventions.
A resident with severe cognitive impairment experienced a fall resulting in a head injury and required neurological assessments per facility policy. Documentation of these assessments was entered by the DON based on a paper form completed by an agency RN, but the original documentation could not be found, resulting in an incomplete and inaccurate medical record.
Three residents experienced falls due to the facility's failure to implement and maintain required fall prevention interventions, including missing bed alarms, fall mats, accessible call lights, and non-skid socks. Timely fall risk assessments were not completed after multiple incidents, and staff did not consistently follow care plan interventions, resulting in injuries and hospitalizations.
A resident with Parkinson's Disease did not receive Apomorphine HCl (Apokyn) as ordered due to staff failing to prime the injection pen and not administering PRN doses as needed. This resulted in the resident experiencing more frequent and prolonged freezing episodes, with increased symptoms and psychosocial distress. The facility's policy did not address priming requirements for multidose cartridge pens, and medication records did not reflect PRN administration during observed episodes.
A nurse did not check the placement of a gastrostomy tube before administering medications and failed to flush the tube between two different medications for a resident, contrary to facility policy.
A nurse did not wear a gown while providing suprapubic catheter care to a resident on Enhanced Barrier Precautions (EBP) due to a history of ESBL and recurrent UTIs, despite following other infection control protocols and the presence of isolation signage and supplies. The nurse later acknowledged the omission, and the DON confirmed EBP was required for this resident.
Deficiencies were identified in infection prevention and control, including failure to implement Enhanced Barrier Precautions for a resident with chronic wounds, lack of hand hygiene and equipment disinfection during blood glucose monitoring, and inadequate response to a norovirus outbreak. Symptomatic staff were not restricted from work, isolation and contact precautions were not consistently followed, and outbreak signage was not posted. These failures led to widespread illness among residents and staff, and one resident died from acute renal failure related to viral gastroenteritis. Additional lapses included improper monitoring of water temperatures and failure to follow PPE and cleaning protocols for residents on contact precautions.
Three residents experienced significant weight loss due to the facility's failure to promptly implement nutritional interventions, follow dietitian recommendations, update care plans, and notify the physician, dietitian, and resident representatives. Delays in supplement orders, lack of timely documentation, and unclear staff responsibilities contributed to ongoing weight loss and inadequate care planning.
A licensed practical nurse worked in the facility without a current state license on file, as required by facility policy and job description. Human Resources was unable to provide updated licensure documentation, and records showed the LPN continued to work after the license had expired, potentially affecting all residents.
Two residents experienced medication administration errors, including failure to follow pharmacy instructions for eye drops, use of an incorrect strength of topical gel without a physician order, late administration of scheduled medications, and withholding of insulin without physician notification or documentation. Nursing staff did not notify providers or document these deviations as required.
Surveyors found that medications for discharged residents were not removed from storage, opened insulin vials were not individually dated, and a nurse pre-poured unidentified pills into cups labeled only with initials and room numbers. Staff confirmed these practices did not follow facility policy for medication storage, labeling, and administration.
Two residents with complex medical needs were not provided with appropriate seating or assistance during meals, resulting in difficulty accessing their food and leaving the dining room without eating. Staff were observed standing over the residents to assist with feeding and cutting food, contrary to facility policy and best practices for promoting dignity and independence.
A resident admitted to hospice care did not have an individualized care plan with measurable interventions developed by facility staff. The DON and Care Plan Coordinator confirmed that such a plan should have been in place, but it was not found in the communication book, and the hospice plan of care was only provided after further inquiry.
A resident's care plan was not updated in a timely manner to reflect a change in code status after the resident signed a form indicating a do-not-resuscitate (DNR) preference. The care plan continued to list the resident as full code despite documentation of the DNR status in the medical record. Staff acknowledged the delay in updating the care plan.
A resident with dysphagia, dementia, and other medical conditions was observed with significant crusty secretions in the mouth and on the lips, indicating a lack of required oral care. Facility policy requires oral hygiene for residents needing assistance, and the ADON confirmed this expectation, particularly for those with swallowing difficulties.
A resident with multiple pressure ulcers did not receive timely assessments, physician-ordered treatments, or pressure relieving interventions. Staff failed to document new wounds, update the care plan, or consistently use pressure relieving devices, resulting in inadequate management of the resident's skin integrity.
The facility did not obtain physician orders for oxygen use and failed to ensure proper cleaning and storage of nebulizer equipment for two residents receiving respiratory care. One resident's nebulizer mask and tubing were left uncovered and not stored in a bag as required, and another resident used oxygen without a physician order in place. Facility policy for respiratory equipment hygiene and documentation was not followed.
Three residents were prescribed psychotropic medications without periodic assessment, documentation of nonpharmacological interventions, or identification and tracking of targeted behaviors. One resident received duplicate antipsychotic therapy without justification, and in all cases, required documentation and behavioral tracking were missing, as confirmed by the DON and corporate nurse consultant.
A resident did not receive prescribed pain and antifungal medications following hip replacement surgery, leading to significant medication errors. The facility failed to administer Hydrocodone/Acetaminophen and Clotrimazole Vaginal Cream as ordered, resulting in the resident experiencing pain and ongoing infection symptoms. The DON confirmed the errors were due to delays in receiving correct prescriptions, and the MD emphasized the importance of following discharge orders.
A facility failed to maintain sanitary practices during medication administration, as observed with an RN and the DON handling medications with bare hands after touching shared surfaces. This practice, acknowledged as an infection control concern by the Administrator, potentially affected all 81 residents, despite the facility's policy emphasizing hand hygiene.
A facility failed to provide adequate pharmaceutical services by not acquiring and administering medications as prescribed for a resident. The resident's family reported missing Ativan doses and found pills in the resident's bed, indicating nurses were not ensuring medication intake. The MAR showed missed doses and lack of documentation for a B-12 injection. The DON acknowledged issues with agency nurses' access to backup medications and prescription renewal delays. The facility's policy on medication administration was not followed, contributing to the deficiency.
A resident with a stage 4 pressure ulcer on the left hip did not receive consistent wound care as per the treatment plan, leading to an infection. The Treatment Administration Records showed multiple missed treatments across various shifts. Despite the nurse practitioner's awareness and communication to staff, the wound care was not adequately performed, resulting in the wound becoming infected.
A resident with esophageal cancer and dysphagia experienced respiratory distress during a meal. Staff were unable to locate and operate suctioning equipment promptly, delaying emergency airway management. Despite eventual suctioning by an APRN, the resident's condition did not improve, and they passed away later that evening.
The facility failed to maintain a full-time DON, affecting resident care. The former DON resigned, and a new hire did not join. Regional nurses provided part-time coverage, but a decline in care, especially wound care, was noted. The facility's assessment highlighted the need for a DON to ensure competent care.
The facility failed to employ a full-time licensed Nursing Home Administrator, leading to a decline in resident care. The previous administrator was involved in an accident, and the Human Resources Manager was being considered for the role but had not yet applied for the necessary license. A Nurse Practitioner noted a decline in care, and the facility's assessment highlighted the need for an administrator to support the 77 residents.
The facility did not conduct a quality improvement review after a resident's death due to aspiration. The incident was not reported to corporate staff or regional nurses, and no reviews or staff education were conducted. The former DON was identified as responsible for initiating QAPI reviews and corrective actions, which were not done. The facility's QAPI plan, which mandates evaluating systems and implementing corrective actions, was not followed.
A facility failed to honor a resident's advance directive preferences during a choking incident. Despite having a DNR order, the resident's POLST form indicated a preference for selective treatment and hospital transfer if necessary. Staff did not call EMS or notify the Health Care Power of Attorney during the emergency, leading to the resident's deterioration and eventual death. The Health Care Power of Attorney considered this negligence.
A resident with esophageal cancer and dysphagia experienced respiratory distress during a meal, highlighting a deficiency in staff competency and equipment handling. Multiple staff members were unable to locate or operate the suctioning equipment, delaying necessary care. The facility had not provided recent training on the equipment, contributing to the issue.
The facility failed to provide quarterly financial statements to two residents with no cognitive impairment, as required by policy. Both residents reported not receiving their statements, and the facility could not provide documentation confirming the statements were issued. The deficiency was identified during a survey.
A resident with severe cognitive impairment and a history of falling developed a significant bruise on the left knee, which was not reported to a physician or provider. The bruise, likely related to recent hip surgery, was documented in a wound assessment but lacked physician notification, as confirmed by the wound nurse and medical director.
The facility failed to prevent accidents and falls for three residents. One resident was injured due to sharp edges on a wheelchair during a lift transfer. Another resident fell while attempting to transfer from bed to wheelchair without assistance, as the bed and wheelchair were not positioned correctly. A third resident fell while trying to transfer from a wheelchair to bed, as they were left unattended without a chair alarm. All residents had severe cognitive impairments, increasing their risk of falls.
A resident with severe cognitive impairment and a history of inappropriate touching was left unsupervised, leading to an incident of sexual abuse against another resident. Despite previous incidents and a care plan outlining necessary interventions, the facility failed to consistently implement one-to-one monitoring, resulting in repeated inappropriate behaviors. Staff interviews confirmed gaps in supervision and monitoring, contributing to the deficiency.
The facility did not ensure staff received training in areas identified in its assessment, affecting all 67 residents. Required topics included communication, resident rights, infection control, antibiotic stewardship, and annual CNA in-service training. No documentation was available to confirm training was conducted.
The facility failed to conduct ongoing training in effective resident care communications for all staff, potentially affecting all 67 residents. Despite the facility's assessment including effective communication as a training topic, a review of in-services over the past year showed no documentation of such training. The Administrator was unable to provide additional documentation confirming that this training had occurred.
The facility failed to conduct ongoing training in Resident Rights for all staff, potentially affecting all 67 residents. Despite the facility's assessment including Resident Rights as a training topic, there was no documentation of such training conducted in the past year. The Administrator was unable to provide additional documentation when requested.
The facility did not conduct ongoing staff training on its QAPI program, as required by its assessment. The administrator could not provide documentation of any all-staff QAPI training over the past year, potentially affecting all 67 residents.
The facility failed to conduct ongoing staff training on its Infection Control Program, as required by its infection prevention and control program. Despite the facility's assessment including staff training, there was no documentation of any all-staff training conducted over the past year. The administrator could not provide additional documentation when requested, potentially affecting all 67 residents in the facility.
The facility failed to provide CNAs with the required 12 hours of annual in-service training, including dementia care, affecting all 67 residents. The administrator confirmed the absence of a tracking system for training attendance and the cessation of electronic training software use. Documentation for CNAs V5, V8, V9, V10, and V21 lacked evidence of dementia training or completion of required hours.
Failure to Follow Diabetic Orders, Notify of Changes in Condition, and Complete Post-Fall Assessments
Penalty
Summary
The deficiency involves multiple failures to implement diabetic care and follow physician orders, to notify providers and family of changes in condition, and to complete required post-fall assessments for several residents. One resident with long-standing type 1 diabetes was admitted after hospitalization for dehydration and hyperglycemia, with hospital discharge orders for Novolog insulin per sliding scale three times daily, insulin glargine 12 units every evening, and frequent blood glucose monitoring. These hospital orders, including the Novolog sliding scale and instructions to monitor blood glucose regularly, were not fully transcribed into the facility’s physician orders or MAR, and a baseline care plan addressing diabetes and the use of a continuous glucose monitor was not created. Blood glucose monitoring three times daily before meals was not consistently documented until several days after admission, and some blood glucose readings were missing. Staff obtained blood pressures on the arm where the continuous glucose monitor was located, despite the device manual indicating that pressure on the sensor can affect readings, and there was no order or care plan instruction to avoid that arm. For this same resident, nursing notes show that insulin glargine was held on the evening of admission due to vomiting and lack of food, without notifying the provider. The resident refused bolus tube feedings on subsequent days, and these refusals were not reported to a provider. Nursing documentation shows episodes of very high blood glucose readings, including “over high/over 400” on the continuous glucose monitor, with additional insulin doses given per immediate orders, but there were gaps in blood glucose checks, including a period where the continuous glucose monitor was not working and the resident refused finger-stick checks. Staff did not consistently notify the physician when the continuous glucose monitor failed or when the resident refused blood glucose checks. The physician later stated that hospital orders for Novolog sliding scale three times daily should have been continued, that staff should have reported the device malfunction and refusals, and confirmed that the lack of appropriate monitoring and insulin administration contributed to the resident’s rehospitalization for diabetic ketoacidosis, with an emergency room glucose level of 1194 mg/dL. Another resident with diabetes had orders for insulin glargine and short-acting insulin (insulin aspart/Novolog) but had numerous doses of both long-acting and short-acting insulin held over multiple months without documentation that the physician was notified. The MAR shows that long-acting insulin glargine was not administered on multiple evenings, and short-acting insulin aspart/Novolog scheduled three times daily was held many times even when blood glucose was greater than 110, despite there being no active order after readmission to hold the short-acting insulin for blood glucose less than 110. The physician later stated this was the first time he became aware that staff were holding long-acting insulin, that he does not order parameters to hold long-acting insulin, and that staff should report any time insulin is held outside ordered parameters. The DON confirmed there was no documentation of provider notification for the held insulin doses and that there was no active order to hold the short-acting insulin. The deficiency also includes failure to timely notify a physician and family of a change in condition following a fall, resulting in delayed treatment of a compression fracture. One resident with severe cognitive impairment experienced an unwitnessed fall and was found sitting on the bathroom floor. Initial assessment documented no injuries, and the resident was returned to the wheelchair. Over the next days, the resident developed increasing lower back pain, became tearful and crying, and required PRN pain medication. Nursing documentation shows that pain was rated as high as 8 on a 1–10 scale, and an LPN obtained orders for a lumbosacral x-ray and PRN ibuprofen. However, there is no documentation that the new onset and increased back pain following the fall was reported to a provider prior to the day the x-ray was ordered, and no documentation that the resident’s family was notified of the pain or the new orders until the day the x-ray results were received and the resident was transferred to the hospital. The family member reported being told only that the resident had fallen and then later that the resident was going to the hospital, without interim updates about pain or diagnostic testing. Post-fall assessment deficiencies were also identified. For the resident with the unwitnessed fall, neurological assessments were documented at multiple time points after the fall, but all entries contained the same set of vital signs recorded at the initial time, indicating that vital signs were not actually reassessed and documented as required. The RN acknowledged that neurological checks should be completed every 15 minutes for one hour, every 30 minutes for two hours, then every four hours for 24 hours with vital signs each time, and confirmed that all documented checks showed the same vital signs from the initial assessment. Another resident with diabetes, a history of subdural hematoma and subarachnoid hemorrhage, and current anticoagulant therapy (Eliquis) experienced a witnessed fall while attempting to self-transfer. There was no documentation that blood glucose was checked at the time of the fall or that neurological assessments were initiated, despite the resident’s diabetes and prior brain bleed. The LPN involved stated that blood glucose was not checked because the resident was alert and did not appear hypoglycemic, and that neurological assessments were not started because the fall was witnessed. The DON later stated that neurological assessments should be initiated for any unwitnessed falls, but the documentation shows that required neurological and blood glucose assessments were not completed as outlined in facility policies and care plans.
Failure to Implement Fall Interventions, Accurate Risk Assessments, and Thorough Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and care plan fall interventions, accurately complete fall risk assessments, and thoroughly investigate falls for three residents. For one cognitively intact resident who required supervision/touch assistance for transfers and had an active care plan identifying fall risk and use of bed and chair alarms, fall risk assessments completed around the time of two falls incorrectly documented that the resident was not at risk for falls, was ambulatory, and used only 1–2 high‑risk medication classes. Medication administration records showed the resident was actually receiving multiple medications from the listed high‑risk classes. After two falls in which the resident attempted to self‑transfer to the bathroom and into bed, the fall investigations did not include staff statements identifying when the resident was last observed or toileted. An interdisciplinary note added bed and chair alarms as an intervention, yet surveyors observed the resident seated in a recliner without an alarm in place, and the CNA who assisted the resident into the recliner was unsure whether an alarm was required there. Another resident with severe cognitive impairment, total incontinence, and a need for substantial/maximal assistance with transfers was found on the floor of a hallway bathroom after reportedly trying to go to the bathroom. A CT scan showed an L1 vertebral fracture. The fall investigation contained three staff statements, including one CNA who reported toileting the resident after lunch and then taking the resident to the dining room, but there was no documentation of whether the resident was observed after that time or whether any staff had transferred the resident onto the toilet and left the resident unattended. Staffing records showed multiple CNAs and nurses on duty at the time, but interviews with CNAs and an RN indicated they had last seen the resident in the dining room and were unaware the resident was in the hallway bathroom. Nursing documentation noted the resident had a chair alarm, but the active care plan did not include chair alarm use, and the DON later confirmed there was no documentation of bed or chair alarms in the record prior to the recent fall despite staff reporting alarm use. A third resident with moderate cognitive impairment, total incontinence, and dependence on staff for toileting and transfers had a care plan addressing incontinence with frequent checks and changes, but fall risk assessments incorrectly documented that the resident received only one or two medications from high‑risk drug classes. Medication records showed the resident was actually receiving several medications from those classes. The resident experienced an unwitnessed fall in the room, where the resident was found on the floor on a fall mat after reportedly attempting to get out of bed due to seeing children; the fall investigation did not document staff interviews or when the resident was last checked or toileted. A subsequent witnessed fall occurred when a CNA, present for the roommate, saw the resident slipping out of bed and braced the resident to the floor on the mat; again, the investigation did not document when the resident was last checked or toileted. The DON confirmed that the fall investigations for this resident lacked documentation of last checks or toileting and that the fall risk assessments did not accurately reflect the resident’s medications.
Failure to Follow Discharge and Physician Orders for Anticoagulant Therapy
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and hospital discharge instructions regarding anticoagulant therapy, resulting in repeated significant medication errors for one resident. The facility’s policy on transcription of physician orders requires review and clarification of hospital discharge summaries with the physician and discontinuation of previous orders when medication orders change. The resident, who had a care plan identifying risk for bleeding complications related to anticoagulant use, had recently sustained a subdural hematoma and subarachnoid hemorrhage after a fall and was treated in the hospital. The hospital discharge summary documented that neurosurgery directed that aspirin and any antiplatelet/anticoagulant medications be held until a follow-up visit with repeat imaging, and Eliquis was not listed among the active discharge medications. Despite these instructions, the resident’s Medication Administration Records show that Eliquis 5 mg twice daily was administered on multiple dates after readmission. The February MAR documents Eliquis was given from early to mid-month and again from mid- to late-month, and the March MAR shows additional doses administered, with the medication intermittently placed on hold. A physician progress note later documented to continue holding Eliquis until neurosurgery re-evaluation, and a neurosurgery note indicated the brain bleed had resolved and recommended individualized discussion before resuming Eliquis. The attending physician stated that Eliquis should have been held upon readmission, and the DON acknowledged that the Eliquis order was initially missed when cross-referencing prior orders with the hospital discharge orders, and that the medication was resumed again due to a hold order being entered with a limited duration, leading to further doses being given before the error was identified.
Widespread Failures in Pressure Ulcer Prevention, Assessment, and Infection Control
Penalty
Summary
Multiple failures in care were identified for residents with pressure ulcers, including a lack of timely repositioning, incomplete and delayed skin assessments, and failure to update care plans with appropriate interventions. One resident, who was severely cognitively impaired and completely dependent on staff for all activities of daily living, developed 18 separate facility-acquired pressure ulcers over several months, including multiple Stage 4 and Stage 2 ulcers. Staff did not consistently follow physician orders for wound care, did not provide wound supplements as ordered, and failed to obtain laboratory tests in a timely manner. Observations revealed that the resident was not repositioned or provided incontinence care for extended periods, and care plans did not reflect all current wounds or necessary interventions. During wound care procedures, staff failed to prevent cross-contamination. For example, a nurse's gown made contact with an open Stage 4 pressure ulcer, and the nurse continued the dressing change without changing gloves or cleansing the wound again. In another instance, a resident's sacral wound came into contact with a contaminated incontinence brief, and the wound was not re-cleansed before a new dressing was applied. Staff admitted to being aware of these breaches in infection control but did not take corrective action at the time. Additionally, wound care was not always performed according to the most current physician orders, as staff found the orders confusing and did not consistently review updated wound progress notes. Other residents also experienced deficiencies in care. One resident developed a Stage 4 pressure ulcer on the left ischium and a Stage 2 ulcer on the coccyx, both acquired in the facility. Staff failed to identify and assess new wounds promptly, did not transcribe or provide ordered wound supplements and dressing changes, and did not update care plans with wound interventions. In another case, a resident with a Stage 4 pressure ulcer on the right great toe did not receive proper infection control during dressing changes, and a risk management assessment was not completed. These failures resulted in wound infections requiring antibiotic treatment and contact isolation.
Removal Plan
- The facility reviewed all resident wound progress notes and Physician Order Sheets (POS) and updated them as needed prior to the resident's next scheduled treatment change.
- Director of Nurses (DON) and Regional Clinical Nurse Consultant oversee this.
- All licensed nurses were educated on the facility Physician Ordering process, including entering and processing policy.
- All licensed nurses were educated on the facility documentation policy using an Electronic Medical Record (EMR), including timeliness, accuracy, relevance, and completeness of entries.
- The facility developed and implemented a plan to ensure staff who identify residents acquiring new pressure sores document the sore assessment, make the appropriate notifications, reassess the newly acquired wound within 24 hours, and obtain consent for the resident to see Wound Physician.
- The facility will ensure the direct care nurse reviews the Treatment Administration Record (TAR) prior to conducting wound care.
- The facility developed a process to ensure physician orders for laboratory tests are entered in the resident EMR timely.
- The facility has a process to ensure staff develop and provide interventions to prevent pressure ulcers from forming and/or worsening.
- All licensed nurses were provided education on the facility Pressure Injury and Skin Condition Assessment policy.
- All licensed nurses and CNAs were educated on the facility Pressure Ulcer Prevention Policy.
- All CNAs were provided education on how to access wound care prevention interventions.
- All licensed nurses and CNAs were educated on the facility Physician-Family Notification Policy.
- All licensed nurses and CNAs were educated on the facility Basic Care Plan Policy.
- All licensed nurses and CNAs were educated on the facility Resident Round guidelines.
- The facility Dietary Manager was educated on following physician diet orders, including ensuring residents with wound supplements were served the correct diet.
- All licensed nurses, CNAs, and dietary staff were educated on the facility Diet Orders guidelines.
- All licensed nurses were educated on the facility admission of Resident guidelines.
- The facility Care Plan Coordinator was educated on the facility Comprehensive Care Plan review.
- The facility Interdisciplinary Team (IDT) members were educated on the facility Comprehensive Care Plan policy.
- The facility held a Quality Assurance Performance Improvement (QAPI) meeting.
- The facility conducted a facility-wide audit of all resident wound care plans.
- The facility initiated audits to ensure residents with pressure ulcers have correct physician orders in the EMR, completed assessments, revised care plans, reviewed wound physician progress notes, and reviewed and updated the resident Physician Order Set (POS).
- The facility created a Quality Assurance Tool to verify these practices are occurring.
- The facility presented an abatement plan to remove the immediacy.
Insufficient CNA Staffing Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient Certified Nursing Assistant (CNA) staffing to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. On a specific day, only 7 CNAs were present, distributed as 3 on the East wing, 2 on the Middle wing, and 2 on the West wing, which did not meet the facility's own staffing plan of 8 CNAs for the day shift. Resident Council Meeting Minutes over several months documented ongoing concerns about delayed call light responses, water not being passed in the evenings, and missed showers on scheduled days. The facility's assessment indicated a significant number of residents with stage three or four pressure ulcers and a census of 83 residents, with 41 requiring two-person assistance for transfers or care. Staffing sheets confirmed that multiple day and night shifts were staffed below the facility's stated minimums. Staff interviews corroborated the insufficient staffing, with CNAs and a Registered Nurse reporting frequent short-staffing, increased workloads, and difficulty in providing timely care, including repositioning residents and responding to call lights. The Director of Nursing confirmed that actual staffing did not match the facility's staffing plan and acknowledged the challenges in maintaining adequate coverage due to call-offs and recent staff resignations. The deficiency affected all residents in the facility, particularly those requiring higher levels of assistance.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 28 observed opportunities, resulting in a 10.7% error rate. During a medication administration observation, a registered nurse administered incorrect doses of Sertraline, Levothyroxine, and Calcium + Vitamin D3 to a resident. The resident's physician orders and medication administration records showed discrepancies, including the administration of multiple doses of Levothyroxine that exceeded the prescribed amount over several days. Laboratory results indicated an abnormal thyroid stimulating hormone (TSH) level for the resident during this period. The nurse involved acknowledged the errors during an interview, stating she believed she had all the correct medications but made mistakes. The facility's policy requires a triple check of the five rights of medication administration at three separate steps, but this process was not effectively followed. The Director of Nursing confirmed that all medications are expected to be administered as ordered and that any errors or omissions must be reported to the physician and the resident's family.
Failure to Maintain Contact Isolation Precautions for Resident with Infected Pressure Ulcers
Penalty
Summary
A deficiency occurred when staff failed to maintain contact isolation precautions for a resident with multiple medical conditions, including infected pressure ulcers. The resident was documented as severely cognitively impaired and completely dependent on staff for all activities of daily living. Physician orders required contact isolation precautions due to a wound infection, and appropriate signage and personal protective equipment (PPE) were present at the resident's room. Despite these measures, an LPN entered the resident's room without donning a gown or gloves to sanitize the bedside table, using bare hands to move the table and then exiting the room without performing hand hygiene. The LPN then handled wound dressing supplies outside the room, which were later used on the resident's infected pressure ulcers. The Director of Nursing confirmed that proper PPE should have been used and that the wound supplies were contaminated as a result of these actions. Facility policy required contact precautions for residents with infections that could be transmitted through direct or indirect contact.
Failure to Report Allegations of Neglect and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of neglect and injuries of unknown origin to the administrator and the state survey agency for three residents. According to the facility's own Abuse Prevention and Reporting policy, staff are required to immediately report any allegations or suspicions of abuse or neglect to the administrator, and to notify the state survey agency within specified timeframes depending on the severity of the incident. However, in the cases reviewed, these procedures were not followed. For one resident with severe cognitive impairment and incontinence, staff made derogatory remarks about the resident's past, and there were allegations that a CNA delayed care due to these remarks. The administrator was not made aware of these concerns until the surveyor's interview, and the incident was not reported or investigated as required. In another case, a resident with memory impairment and behavioral issues was found with unexplained bruising and swelling around the eye. The cause of the injury was not witnessed, the resident could not explain it, and the investigation was limited to a few staff interviews. The injury was not reported to the administrator or the state survey agency as an injury of unknown origin. A third resident, who had moderate cognitive impairment and a recent history of hospitalization for a blood disorder, was observed with significant facial bruising. The cause of the bruising was not documented, and there was no investigation or reporting to the administrator or state survey agency. In all three cases, the facility did not follow its own policy for reporting and investigating allegations of neglect or injuries of unknown origin, resulting in a failure to protect resident rights and ensure proper oversight.
Failure to Complete and Document Neurological Assessments and Follow Physician Orders After Resident Injuries
Penalty
Summary
The facility failed to implement physician's orders and complete required neurological assessments for three residents who experienced injuries, specifically head injuries and falls. In one case, a resident fell while moving items in her room, resulting in a head wound requiring stitches and a left arm injury. Although orders were given for a repeat x-ray and an orthopedic follow-up, there was no documentation that these were completed, and neurological assessments were not consistently performed or documented as required. Another resident fell from his wheelchair, sustaining a facial injury and was later diagnosed with a stroke. Despite physician orders for hourly neurological assessments for 12 hours, the documentation did not show that these checks were completed as ordered. The resident was also on medications that could increase bleeding risk, further emphasizing the need for close monitoring, which was not documented. A third resident was found with a bruised and swollen left eye, and neurological checks were initiated. However, the records showed that only a portion of the required assessments were completed, with several scheduled checks missing. The facility's own policy required specific intervals for neurological assessments following head injuries or unwitnessed falls, but these protocols were not followed or documented for the residents involved.
Failure to Maintain Resident Confidentiality and Privacy
Penalty
Summary
Staff at the facility failed to maintain the confidentiality and privacy of a resident's personal and medical information. Multiple staff members, including CNAs, an LPN, and activity aides, discussed the resident's alleged history of abuse and molestation of family members in various locations throughout the facility, such as hallways, the nurses' station, and offices with open doors. These conversations were overheard by other staff and could have been overheard by anyone nearby, including visitors. The information was not only shared among staff but also discussed in a manner that was not discreet or appropriate, violating the facility's policy on resident rights and confidentiality. The resident in question was documented as having severe cognitive impairment. Staff acknowledged that such discussions were inappropriate and against policy, with some expressing discomfort and concern about the relevance of the information to the resident's care. The administrator confirmed that discussing a resident's history in this manner was not appropriate. The facility's own policy emphasized the importance of privacy and confidentiality for all residents, which was not upheld in this instance.
Failure to Report, Investigate, and Document Injury of Unknown Source
Penalty
Summary
The facility failed to follow its abuse policy regarding the reporting, investigation, and documentation of injuries of unknown source for one resident. A resident with moderate cognitive impairment and a recent history of hospitalization for a blood disorder and possible cancer was observed with significant bruising on the right side of her face and arms. The resident was unaware of the cause of the bruising, and her family member confirmed the presence of the bruising on previous days. Despite the facility's policy requiring documentation, investigation, and notification of the physician and representative for injuries of unknown source, there was no documentation of the facial bruising in the resident's medical record, nor was the incident logged in the facility's incident log. Staff interviews revealed that while an LPN was aware of the bruising and had notified the family, the Director of Nursing and the facility administrator were not informed of the injury. No investigation was conducted to determine the cause of the bruising, and the physician was not notified as required by policy. The lack of documentation, investigation, and appropriate notifications constituted a failure to adhere to the facility's established procedures for handling injuries of unknown source.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for two residents. For one resident with memory impairment and behavioral issues such as crawling on the floor and ramming into objects, staff discovered bruising and swelling around the left eye, along with dried blood above the eyebrow. The resident was unable to explain the injury, and no staff witnessed the incident. The investigation consisted only of two CNA interviews, with no further documented attempts to determine the cause. The Director of Nursing confirmed that the cause of the injury was not witnessed and that the resident could not explain it, but did not consider it an injury of unknown origin, despite the lack of explanation or observation of the event. Another resident, who had moderate cognitive impairment and a recent diagnosis of a blood disorder, was found with facial bruising. The resident was unaware of the bruising and could not explain its cause. Staff attributed the bruising to the resident's low platelets and blood disorder, but there was no documentation of the injury in the medical record, nor was there any investigation into the cause. The DON and administrator were not aware of the injury and confirmed that no investigation had been conducted. The facility's policy requires that all injuries of unknown origin be reported and investigated, including interviewing all relevant parties and following the same time frames as for abuse investigations. In both cases, the facility did not follow its policy, as there was insufficient investigation and documentation regarding the injuries of unknown origin for the two residents.
Failure to Thoroughly Investigate Resident Fall and Identify Root Cause
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident with severe cognitive impairment who requires supervision and assistance while ambulating. The resident, who uses a wheelchair and wheeled walker, attempted to get dressed and access her closet without staff assistance, resulting in a fall that caused a head injury requiring stitches and a splint for her left arm. At the time of the incident, staff were present in the hallway, and a CNA witnessed the resident walking unaided and falling but was unable to intervene in time. The resident was not using her walker and it was unclear if she was wearing appropriate footwear. The facility's fall investigation did not identify the root cause of the fall, as required by policy. The incident report lacked documentation regarding the resident's footwear and whether the walker was in use, both of which are critical factors in determining appropriate post-fall interventions. The DON confirmed that the investigation relied solely on a written statement from the CNA and did not include an interview or comprehensive assessment of the circumstances surrounding the fall. As a result, the facility did not ensure that all relevant information was gathered to inform effective interventions to prevent future accidents.
Failure to Maintain Accurate Medical Record After Resident Fall
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident who experienced a fall. According to the facility's policies, neurological assessments are required after a head injury or as ordered by a physician, and these assessments must be documented in the resident's medical record. The resident, who had severe cognitive impairment, fell and sustained a head injury, resulting in hospitalization and subsequent return with stitches and bruising. Although neurological assessments were documented in the electronic record, the Director of Nursing later confirmed that these entries were transcribed from a paper form completed by an agency RN, and the original documentation could not be located. No additional documentation for the neurological assessments was available.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for three residents, resulting in falls and injuries. One resident with a history of falls, severe cognitive impairment, and multiple comorbidities experienced an unwitnessed fall while attempting to use the bathroom. At the time of the fall, required interventions such as a bed alarm, fall mat, and accessible call light were not in place, despite being documented in the care plan. The resident sustained a right femoral fracture and a laceration to the right temporal lobe, requiring emergency medical treatment and resulting in significant pain and a decline in condition. Staff interviews confirmed that fall interventions were not consistently implemented, and it was common practice for night shift staff to partially dress residents to expedite morning routines, which contributed to the incident. Two additional residents with histories of falls and cognitive or mobility impairments did not receive timely fall risk assessments as required by facility policy. Documentation showed that fall risk assessments were not completed after multiple falls or at required intervals. For one resident, the wheelchair alarm was not functioning at the time of a fall, and there were no documented interventions or orders to ensure the alarm was routinely checked. Another resident, identified as high risk for falls, was not wearing non-skid socks as specified in the care plan, and staff confirmed this intervention was not in place at the time of observation. The facility's fall prevention policy required individualized assessments and the implementation of appropriate interventions, including supervision and assistive devices. However, observations, interviews, and record reviews demonstrated that these measures were not consistently followed. Staff were not always aware of or did not implement care plan interventions, and required assessments were missed after falls and significant changes in condition. These failures resulted in preventable falls and injuries among residents at risk.
Failure to Administer Medication per Manufacturer's Directions and Physician Orders
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, functional quadriplegia, COPD, type II diabetes, dysphagia, and a gastrostomy tube was dependent on staff for activities of daily living and was cognitively intact. The resident had physician's orders for Apomorphine HCl (Apokyn) to be administered subcutaneously before meals and as needed for freezing episodes related to Parkinson's Disease, with specific instructions to prime the pen according to the manufacturer's directions before each injection. On one occasion, a registered nurse administered the medication without priming the needle, and upon interview, the nurse stated that priming had never been performed. The facility's policy on subcutaneous injections did not address the need for priming multidose cartridge pens. The resident and a family member reported that the medication was not always administered as ordered, both in terms of timing and use of PRN doses, resulting in more frequent and prolonged freezing episodes. Medication administration records confirmed that PRN doses were not documented during episodes observed by the family. The facility's contracted pharmacist confirmed that failure to prime the pen would result in the resident not receiving the correct dose, especially with small-volume medications, potentially affecting the medication's efficacy. The lack of adherence to administration instructions led to the resident experiencing increased symptoms of Parkinson's Disease and psychosocial harm.
Failure to Verify Feeding Tube Placement and Flush Between Medications
Penalty
Summary
A registered nurse failed to follow facility policy during the administration of medications via a gastrostomy tube for one resident. Specifically, the nurse did not verify the placement of the feeding tube by aspirating for stomach contents before administering medications, as required by the facility's protocol. Additionally, the nurse did not flush the tube with water between administering two different crushed oral medications, which is also mandated by policy to ensure proper medication delivery and tube patency. These actions were observed during medication administration and later confirmed by the nurse in an interview.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when a registered nurse performed suprapubic catheter care for a resident with a history of dementia, benign prostatic hypertrophy, obstructive and reflux uropathy, and a suprapubic catheter, who also had a documented history of ESBL in the urine and recurrent urinary tract infections treated with antibiotics. During the procedure, the nurse followed hand hygiene and glove protocols but failed to wear a gown as required under Enhanced Barrier Precautions (EBP), despite the presence of isolation signage, supplies, and containers for transmission-based precautions. The nurse later acknowledged that a gown should have been worn for EBP, and the Director of Nursing confirmed the resident was on EBP due to the suprapubic catheter and ESBL history.
Widespread Infection Control Failures During Norovirus Outbreak and Routine Care
Penalty
Summary
Multiple deficiencies in infection prevention and control were identified, including the failure to implement Enhanced Barrier Precautions (EBP) for a resident with chronic stage two pressure ulcers. Staff entered the resident's room and provided direct wound care without donning required personal protective equipment such as gowns, and there was no EBP signage or PPE cart at the room entrance. The Assistant Director of Nursing confirmed a misunderstanding of EBP requirements, believing they only applied to open wounds and indwelling devices, despite the facility's policy stating that chronic wounds, including pressure ulcers, require EBP. Hand hygiene and equipment disinfection protocols were not followed during blood glucose monitoring. A registered nurse failed to perform hand hygiene before and after checking a resident's blood sugar and did not disinfect the shared blood glucose meter after use. The nurse confirmed the lapse and noted the absence of disinfectant wipes in the medication cart, contrary to facility policy requiring cleaning and sanitizing of medical devices between uses and adherence to hand hygiene protocols. During a norovirus outbreak, the facility failed to restrict symptomatic staff from work, did not implement timely isolation and contact precautions, and did not post outbreak signage at facility entrances. Symptomatic staff, including dietary aides and CNAs, continued to work or returned before being symptom-free for the required period. Staff were observed entering isolation rooms without appropriate PPE, and hand hygiene was not consistently performed after resident care or handling contaminated items. The outbreak resulted in widespread illness among residents and staff, and one resident contracted norovirus and subsequently died from acute renal failure related to viral gastroenteritis. Additionally, the facility failed to monitor and document hot water temperatures and flush water lines as required to prevent Legionella, and did not ensure proper use of PPE and cleaning protocols for residents on contact precautions.
Failure to Implement and Communicate Timely Nutritional Interventions for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to implement timely and appropriate nutritional interventions, follow dietitian recommendations, update care plans for weight loss, and notify the dietitian, physician, and resident representatives of significant weight loss for three residents. For one resident with moderate cognitive impairment and pressure ulcers, significant weight loss was not reported promptly to the dietitian or physician, and care plans were not updated to address the weight loss. The resident experienced ongoing poor meal intake, and there were delays in implementing recommended nutritional supplements. Family notification of the weight loss was also delayed, and the care plan was not updated until months after the initial weight loss was documented. Another resident, also with moderate cognitive impairment and a history of congestive heart failure and fluid restriction, experienced substantial weight loss over several months. The resident's nutritional supplement orders were not implemented in a timely manner, and there was a lack of documentation that the physician was notified of the ongoing weight loss or of the resident's reported depression. The care plan did not address the weight loss, and staff were unclear about the process for updating care plans and notifying appropriate parties. A third resident, who was cognitively intact and admitted with a stage four pressure ulcer, also experienced significant weight loss. The care plan was not updated to reflect the weight loss or new interventions, and there was no documentation that the physician was notified. Recommendations from the dietitian were not implemented promptly, and the resident's food preferences were not consistently reflected in meal planning. Staff interviews revealed confusion about roles and responsibilities for monitoring, reporting, and care planning related to weight loss.
Failure to Ensure LPN Maintained Current State License
Penalty
Summary
The facility failed to ensure that a licensed staff member maintained a current state license as required by policy and job description. Review of the employee file for an LPN revealed that the license on file had expired, and there was no updated license present in either the employee file or the license binder. Human Resources confirmed responsibility for maintaining current licensure documentation and acknowledged the absence of the updated license. Staffing records showed that the LPN continued to work in the facility after the expiration date of the license. The facility's job description for LPNs specifies that a current, unencumbered state license is a qualification for employment. This lapse had the potential to affect all 79 residents residing in the facility.
Medication Administration Errors and Failure to Follow Orders
Penalty
Summary
The facility failed to ensure medications were administered as ordered and in accordance with pharmacy instructions, resulting in a medication error rate of 20% (five errors out of 25 opportunities). In one instance, a registered nurse did not follow the pharmacy label instructions to turn a Cyclosporine eye drop vial upside down several times before administration and used a 5% menthol gel instead of the prescribed 4% menthol gel for a resident's knee pain, without updating the medication order. The nurse confirmed not realizing the need to agitate the Cyclosporine vial and acknowledged the substitution of the gel strength without physician authorization. In another case, a registered nurse administered a resident's Keppra and Coreg significantly later than scheduled and withheld a scheduled dose of Novolog insulin based on the resident's blood glucose, despite lacking physician-ordered parameters to do so. The nurse did not notify the physician of the late administration or the withheld insulin dose, nor was this documented in the resident's medical record. The Director of Nursing confirmed that such deviations from scheduled medication times and withholding of medications without orders require physician notification and documentation, which did not occur in these instances.
Deficiencies in Medication Storage, Labeling, and Disposal
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of medications and biologicals. In one instance, medications belonging to two discharged residents were found in the medication room, despite facility policy requiring that such medications be returned to the pharmacy or picked up by family if brought from home. Staff confirmed that these residents had not been present in the facility for several months, and the medications had not been removed as required. Additionally, two opened vials of insulin for a current resident were found in a single box, with neither vial individually labeled with the date opened, contrary to both facility policy and manufacturer guidelines that require opened vials to be dated and used within a specified timeframe. Further observations revealed that a nurse had pre-poured unidentified pills into medication cups labeled only with resident initials and room numbers, storing them in the medication cart prior to administration. The nurse acknowledged this was done to expedite the morning medication pass due to a high resident load, but also confirmed it was not an acceptable practice. Facility policy specifies that medications should be stored in their original pharmacy-labeled containers and not pre-poured. These findings were corroborated by staff interviews and review of medication administration records.
Failure to Promote Dignity and Independence During Dining
Penalty
Summary
Two residents with significant medical needs, including multiple sclerosis, bilateral cataracts, severe protein deficiency malnutrition, and dysphagia, were not provided care in a manner that promoted their independence and dignity during mealtimes. Both residents were served plated meals on cafeteria trays while others at their table received their meals directly on the table with utensils. One resident was not properly positioned in a low-seated wheelchair, resulting in her shoulders being level with the edge of the dining table, and she struggled to identify and access food on her plate. Staff were observed standing over the residents to cut food and provide feeding assistance, while conversing with each other, rather than engaging with the residents. On another occasion, both residents were again improperly positioned at the table, struggled to eat independently, and ultimately left the dining room without eating their lunch, with no staff providing assistance during the meal. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed that the residents should have been accommodated with appropriate tables and seating to enhance their ability to eat independently and maintain dignity and socialization. Facility policy also requires that staff avoid standing over residents while assisting them to eat and refrain from practices that ignore individual needs and preferences. The observed actions and inactions by staff failed to uphold these standards, resulting in a deficiency related to the residents' rights to dignity and independence during dining.
Failure to Develop Individualized Hospice Care Plan
Penalty
Summary
The facility failed to develop an individualized care plan with measurable interventions for a resident who was admitted to hospice care. The hospice admission evaluation note documented the resident's admission to hospice, but upon review, there was no evidence of a care plan or related communication for the resident in the facility's communication book. The DON confirmed that the resident's care plan should have been present, and the Care Plan Coordinator, who was new to the position, acknowledged that the resident should have had a care plan with interventions in place. The hospice plan of care was only provided after further inquiry, and it was stated that hospice care plans are obtained from the hospice case manager, indicating a lack of timely and facility-developed care planning for the resident's end-of-life needs.
Failure to Timely Update Care Plan for Advanced Directives
Penalty
Summary
The facility failed to review and revise a care plan in a timely manner for one resident regarding advanced directives. The resident signed a code status form indicating a desire not to be resuscitated, which was documented in the medical record. However, the care plan, dated several days after the code status form was signed, continued to list the resident as a full code. The care plan coordinator acknowledged that the code status should have been updated on the care plan as soon as possible after the form was signed. Social services staff also confirmed that the resident's code status should have been entered into the medical record.
Failure to Provide Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary oral care for a resident who was unable to perform activities of daily living independently. According to the facility's oral hygiene policy, oral care is required as part of morning and evening routines, and some residents may need additional care after meals. One resident with diagnoses including dysphagia following a cerebral vascular accident, seizures, anxiety, and dementia with behaviors was observed lying in bed with her mouth open, breathing through her mouth, and exhibiting a large amount of crusty gray secretions on her lips and in her oral cavity. The Assistant Director of Nursing confirmed that all residents requiring assistance with oral care should receive it as needed, especially those with dysphagia.
Failure to Assess, Document, and Implement Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident. Specifically, the facility did not document assessments or obtain treatment orders for newly identified pressure ulcers, did not update the care plan to include pressure ulcers or pressure relieving interventions, and did not timely implement physician-ordered treatments. Observations showed the resident sitting in a stationary chair without a therapeutic cushion on multiple occasions, despite having pressure ulcers on the sacrum and heel. Staff interviews confirmed that pressure relieving interventions, such as wedge cushions or pressure relieving cushions, were not consistently used, and documentation of repositioning and skin assessments was lacking. Record review revealed that the resident was dependent on staff for mobility and incontinence care, had significant weight loss, and was at risk for pressure ulcers according to Braden assessments. The care plan only included general skin integrity monitoring and did not address specific interventions for pressure ulcer prevention or treatment. Physician orders for pressure relieving devices and treatments were not implemented as directed, and there were delays in starting prescribed treatments such as zinc cream. Initial assessments and documentation for new wounds, particularly to the heels, were missing, and there was no evidence that the physician was notified or that preventative measures were put in place in a timely manner. Further, staff interviews and documentation confirmed that weekly skin assessments were not consistently performed or recorded, and the care plan was not updated to reflect the resident's current condition or interventions. The Assistant DON acknowledged the lack of documentation and implementation of pressure relieving interventions, as well as missing shower sheets and incomplete wound assessments. These failures resulted in inadequate monitoring and management of the resident's pressure ulcers.
Failure to Obtain Physician Orders and Maintain Respiratory Equipment Hygiene
Penalty
Summary
The facility failed to obtain physician orders for oxygen use and did not provide proper hygienic care and storage of nebulizer equipment for two residents requiring respiratory care. One resident was observed in bed using oxygen at 3 liters per minute, with their nebulizer mask and tubing left uncovered in an open drawer. The resident reported receiving daily nebulizer treatments, and the medication administration record confirmed four daily Ipratropium-Albuterol nebulizer treatments. However, there was no documented order or schedule for changing the nebulizer tubing. A registered nurse confirmed that the tubing and mask should be changed weekly, cleaned nightly, and stored in a bag, but the equipment was found uncovered and improperly stored. Another resident was observed using oxygen at 2 liters per minute via nasal cannula, stating that oxygen use began after a recent hospital admission. There were no active physician orders for oxygen use in the medical record, and nursing notes documented ongoing oxygen use since admission. The assistant director of nursing acknowledged that physician orders for oxygen and flow rate were required and confirmed that the hospital discharge orders did not include oxygen. The facility's policy required weekly changes and daily cleaning and proper storage of nebulizer equipment, which was not followed in these cases.
Failure to Assess and Document Psychotropic Medication Use and Interventions
Penalty
Summary
The facility failed to periodically assess the use of psychotropic medications, identify and track resident-specific behaviors, attempt nonpharmacological interventions, and avoid duplicate therapy for three residents reviewed for unnecessary medications. For one resident, the Medication Administration Record (MAR) listed antipsychotic and antidepressant medications, but there was no documentation of nonpharmacological interventions or identification and tracking of specific behaviors. Another resident was prescribed both an antipsychotic and an antidepressant, yet there was no documented psychotropic medication assessment, no evidence of attempted nonpharmacological interventions, and no tracking of resident-specific behaviors. A third resident was found to be receiving two different antipsychotic medications concurrently, along with a sleep aid, without documented justification for the duplicate antipsychotic therapy. There was also no psychotropic medication assessment, no documentation of nonpharmacological interventions, and no identification or tracking of resident-specific behaviors for this resident. The Director of Nursing and Corporate Nurse Consultant confirmed that these assessments and interventions should have been documented for all three residents.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer prescribed pain and antifungal medications to a resident following joint replacement surgery, resulting in significant medication errors. The resident, who had undergone hip replacement surgery, was diagnosed with conditions including candidiasis and osteoarthritis. The Physician Order Sheet indicated that the resident was to receive Hydrocodone/Acetaminophen for pain and Clotrimazole Vaginal Cream for a yeast infection. However, the Medication Administration Record showed no documentation of the Hydrocodone/Acetaminophen being administered on the specified date, and the Treatment Administration Record lacked documentation of the Clotrimazole cream being given on multiple occasions. The Director of Nursing confirmed that the medications were not administered as ordered due to delays in receiving the correct prescriptions from the pharmacy. The resident reported experiencing significant pain and ongoing symptoms of infection due to these omissions. The Medical Doctor corroborated that the hospital discharge orders should have been followed, emphasizing that the lack of timely pain management could exacerbate post-surgical pain and that untreated infections could worsen. The facility's policy mandates that medications be administered according to prescriber orders, which was not adhered to in this case.
Infection Control Breach in Medication Administration
Penalty
Summary
The facility failed to adhere to sanitary practices during medication administration, as observed on multiple occasions. A Registered Nurse (RN) was seen manually opening drawers of the medication storage cart, handling medication cards, and using a computer mouse with bare hands. The RN then placed residents' pills into her bare hands before transferring them to a small plastic cup for administration. The RN acknowledged awareness of the improper practice but continued to handle medications in this manner. Similarly, the Director of Nursing (DON) was observed engaging in the same unsanitary practices, stating that this was the standard procedure if hands were considered clean. However, it was pointed out that handling shared surfaces like drawers and computer equipment compromised hand cleanliness. The facility's policy on medication administration emphasizes the importance of good hand hygiene, including thorough handwashing and sanitization after contact with potentially contaminated surfaces. Despite this policy, both the RN and DON were observed violating these guidelines, potentially affecting all 81 residents in the facility. The Administrator acknowledged the infection control concern related to placing pills in bare hands, indicating a recognition of the deficiency in practice. The report does not mention any specific medical history or condition of the residents involved, focusing instead on the procedural lapses observed.
Failure to Administer and Document Medications Properly
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, identified as R1, by not acquiring and administering medications as prescribed. R1's family member, V11, reported that the facility did not have R1's Ativan available for two days and found pills, including Zoloft, in R1's bed, indicating that the nurses were not ensuring R1 took her medication. The Physician Order Sheet for R1 documented orders for Lorazepam (Ativan), Zoloft, and Docusate, with specific administration times, but the Medication Administration Record (MAR) showed missed doses of Ativan and a lack of documentation for a scheduled B-12 injection. The Director of Nursing, V2, acknowledged the unavailability of Ativan due to issues with agency nurses not having access to the facility's backup medications and a delay in obtaining a prescription renewal from R1's primary physician. Additionally, the facility's policy on medication administration requires nurses to observe residents taking and swallowing medications, which was not adhered to, as evidenced by the pills found in R1's bed. The Assistant Director of Nursing, V6, confirmed the absence of documentation for the B-12 injection on the MAR, indicating it may not have been administered. The facility's failure to ensure proper medication administration and documentation, as well as the lack of adherence to their own policies, contributed to the deficiency in meeting R1's pharmaceutical needs.
Failure to Complete Pressure Ulcer Treatments Leads to Infection
Penalty
Summary
The facility failed to complete pressure sore treatments for a resident, identified as R2, who was diagnosed with a stage 4 pressure ulcer on the left hip. The resident's treatment plan included cleansing the wound, applying collagen powder, and packing the wound with a bandage soaked in betadine solution, to be done three times a day and as needed. However, the Treatment Administration Records (TAR) for November and December 2024 documented multiple instances where these treatments were not completed across various shifts. This lack of consistent wound care led to the development of an infection in the resident's pressure wound, as confirmed by a wound culture showing Staphylococcus Aureus and other bacteria. Interviews with the resident and a nurse practitioner revealed ongoing issues with the wound care since September 2024. The resident reported that the dressing changes were sometimes delayed for 24 hours, contributing to the wound's deterioration and subsequent infection. The nurse practitioner acknowledged the inconsistency in treatment administration and noted that despite informing the staff, the wound care was not adequately performed, resulting in the wound becoming infected. The facility's job descriptions for Licensed Practical Nurses and Registered Nurses emphasize the responsibility for administering professional services, including wound care, which was not adhered to in this case.
Failure in Emergency Airway Management Leads to Resident's Death
Penalty
Summary
The facility failed to provide timely emergency airway management and suctioning for a resident in respiratory distress during a medical emergency. This deficiency affected a resident diagnosed with esophageal cancer, dysphagia, and a history of esophageal stricture, who was severely cognitively impaired and required assistance with eating. The resident was on a regular diet with pureed texture and thin liquids due to the risk of aspiration. During a meal, the resident experienced difficulty breathing and was unable to cough up phlegm, leading to a medical emergency. During the incident, staff were unable to locate the necessary suctioning equipment promptly, resulting in multiple trips in and out of the resident's room to gather missing equipment. Despite these efforts, the staff could not get the suctioning equipment to function properly, delaying the emergency airway management and respiratory treatment. The resident remained in distress, with low oxygen saturation and labored breathing, while staff struggled to assemble and operate the suctioning machine. The resident's condition did not improve despite eventual suctioning efforts by an Advanced Practice Registered Nurse (APRN), who retrieved significant amounts of secretions. The resident was placed on oxygen support but continued to deteriorate and passed away later that evening. The facility's failure to provide timely and effective emergency care, including the lack of immediate notification to emergency medical services and the APRN, contributed to the resident's death.
Removal Plan
- V1 [NAME] President of Operations initiated education of all licensed nursing staff regarding Physician-Family Notification - Change of Condition Policy and policy on when to transfer or discharge the resident from the facility.
- All facility nursing staff were in-serviced by V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding the suctioning manufacturer's guidelines for suction machine maintenance including but not limited to machine inspection before each use to ensure there are not cracks, breaks, etc. before using the machine.
- All facility nursing staff were in-serviced by V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding where emergency medical equipment is stored, checking all items for medical emergency are in place weekly per checklist and a nurse is responsible to complete the audit and sign off on the checklist weekly.
- All facility nursing staff were in-serviced by V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding the facility's guidelines for Oropharyngeal Suctioning including but not limited to resident positioning, suctioning process, canister exchange, and documentation.
- All facility nursing staff and Direct Care Staff were in-serviced by the V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding the facility's Code Blue Procedure Policy, including but not limited to CPR for choking event.
- All facility nursing staff and Direct Care Staff were in-serviced by the V1 [NAME] President of Operations and V3/V24 Nurse Managers regarding the facility's Equipment Replacement - Disposable - Nursing Policy including but not limited to suctioning equipment replacement including canister, connection tubing, oral suctioning tool, and sterile suction catheters.
- An impromptu Quality Assurance Performance Improvement meeting was held with V12 Medical Director and staff Interdisciplinary Team to discuss facility deficiencies and an action plan.
- The facility began its audits to ensure staff is knowledgeable of the location of emergency medical equipment, how to use the equipment and how to ensure the required supplies. A Quality Assurance (QA) tool will be completed to verify this practice has occurred. The QA tool will be completed by the Directed of Nurses or designee. There will be oversight of the QA tool by the Regional Nurse Consultants (V27, V28).
Absence of Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) to oversee and coordinate nursing services, which has the potential to affect all 77 residents residing in the facility. On two separate occasions, there was no staff member designated as the DON present at the facility. The President of Operations confirmed that the former DON resigned, and a new DON who was hired decided not to work at the facility. Although regional nurses were covering the building, they were not present full-time. A Registered Nurse at the facility stated that there was no DON to facilitate operations, and a Nurse Practitioner reported a general decline in resident care, particularly in wound care, due to the absence of a DON. The Nurse Practitioner had not seen any regional nursing staff in the building and had reported the decline in care to her superiors. The facility's assessment indicated the necessity of a DON to provide competent support and care for the resident population daily and during emergencies.
Absence of Licensed Administrator Leads to Decline in Resident Care
Penalty
Summary
The facility failed to employ a full-time licensed Nursing Home Administrator as required by the Illinois Administrative Code. This deficiency was identified during a survey when it was observed that the facility had been without a full-time administrator since the previous administrator was involved in a motorcycle accident in September. The President of Operations acknowledged the absence of a licensed administrator and mentioned that the Human Resources Manager was being considered for the role of Administrator in Training, but had not yet submitted the necessary application or fees for the temporary license. The absence of a full-time administrator has reportedly led to a general decline in resident care, as noted by a Nurse Practitioner who expressed concerns about the situation. The facility's assessment, revised during the survey, indicated the necessity of an administrator to provide competent support and care for the residents. At the time of the survey, 77 residents were residing in the facility, and the lack of a licensed administrator was confirmed by the President of Operations, who stated that the process of orienting the Human Resources Manager to the administrator duties was only just beginning.
Failure to Implement Quality Improvement Review After Resident Death
Penalty
Summary
The facility failed to implement a quality improvement review following an adverse event that resulted in the death of a resident due to aspiration. This incident was not reported to corporate staff or regional nurses, as confirmed by the President of Operations, who only became aware of the situation when surveyors arrived. The former Director of Nursing admitted that no reviews or staff education were conducted after the incident, and the Human Resources Manager indicated that the former Director of Nursing should have initiated the Quality Assurance Performance Improvement (QAPI) reviews and corrective actions. The facility's Quality Assurance and Performance Improvement plan, which was modified during the survey, outlines the responsibility of the governance team to evaluate systems, gather data from adverse events, and implement corrective actions, but this was not followed in this case.
Failure to Honor Resident's Advance Directive Preferences
Penalty
Summary
The facility failed to honor a resident's advance directive preferences, specifically regarding life-sustaining treatment. The resident, diagnosed with esophageal cancer and severely cognitively impaired, had a Do Not Resuscitate (DNR) order and a Practitioner Order for Life-Sustaining Treatment (POLST) form indicating a preference for selective treatment, including non-invasive positive airway pressure and hospital transfer if necessary. During a choking incident, the resident was found in respiratory distress, and staff attempted oral suctioning without calling Emergency Medical Services (EMS) or notifying the resident's Health Care Power of Attorney. The resident's Health Care Power of Attorney expressed that despite the DNR order, she would have wanted EMS to be called during the emergency. The facility staff did not notify the Advanced Practice Registered Nurse (APRN) or the Health Care Power of Attorney until after the situation had escalated. The resident's condition deteriorated, and he expired later that day. The failure to call EMS and notify the appropriate parties during the emergency situation was seen as negligence by the resident's Health Care Power of Attorney.
Deficiency in Staff Competency and Equipment Handling
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills required to provide residents with potentially life-saving nursing services. This deficiency was highlighted in the case of a resident diagnosed with esophageal cancer, dysphagia, and a history of esophageal stricture, who was at risk for aspiration. The resident required a pureed diet and thin liquids due to difficulty eating and coughing during meals. During a meal, the resident was found in respiratory distress, coughing, and choking on secretions, which necessitated immediate suctioning and oxygen support. The incident revealed that multiple staff members, including LPNs and MDS coordinators, were unable to locate or properly operate the suctioning equipment. The staff had to repeatedly stop to find missing parts, and the machine was not functional until a registered nurse from another unit intervened. It was noted that the staff involved had not been trained on the facility's suctioning equipment, and the equipment itself was outdated, contributing to the delay in providing necessary care. Interviews with various staff members confirmed the lack of recent training on the suctioning equipment and difficulties in locating it during emergencies. The previous Director of Nursing acknowledged that it had been a significant amount of time since any skills training had been conducted, and most current nurses were likely unfamiliar with the equipment. This lack of training and preparedness resulted in a delay in providing critical care to the resident in distress.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide quarterly financial statements to two residents, R7 and R8, who were reviewed for resident funds. Both residents had a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. R7 reported not receiving a quarterly statement since the facility's ownership changed, and R8 stated she had never received a financial statement from the facility. During the survey, it was confirmed that the residents had not received their quarterly financial statements for the period of 12/30/23 to 3/29/24 until the survey date. The facility's policy, dated 10/01/22, requires that individual financial records be available to residents through quarterly statements and upon request. The Administrator, Regional Nurse Consultant, and Regional Financial Coordinator confirmed the requirement for providing quarterly statements. However, the Administrator was unable to find documentation confirming that R7 and R8 had received their statements, leading to the deficiency being identified during the survey.
Failure to Notify Physician of Resident's Significant Bruise
Penalty
Summary
The facility failed to notify a physician or provider of a significant bruise on a resident's knee, which was identified as a deficiency during a survey. The resident, who was admitted to the facility with a history of falling and severe cognitive impairment, had a dark purple bruise on the left knee of unknown origin. The bruise was documented in a wound assessment report, but there was no record of physician notification. A family member of the resident reported the bruise, and the wound nurse confirmed that the physician had not been notified, acknowledging that it should have been done. The medical director later stated that the bruise was likely related to the resident's recent left hip surgery and confirmed that nurse practitioners should have been informed to assess the bruise. The failure to notify the physician or provider of the bruise was identified as a deficiency, as it prevented timely medical assessment and intervention for the resident's condition.
Failure to Prevent Accidents and Falls
Penalty
Summary
The facility failed to maintain a safe environment for residents, leading to injuries and falls. One resident, identified as R10, suffered a bruise and a skin tear during a mechanical lift transfer due to sharp edges on the footrests of their wheelchair. The injuries were discovered by a nurse who noted that the wheelchair had protruding metal with visible sharp edges, which was the cause of the injuries. Another resident, R2, experienced a fall while attempting to transfer from bed to wheelchair without assistance. The resident's care plan indicated a need for the wheelchair to be placed next to the bed in a locked position, and the bed height adjusted so the resident's feet could touch the floor. However, the bed was not in the correct position, and the wheelchair was too far from the bed, contributing to the fall. The resident had a history of falls and severe cognitive impairment, which increased the risk of such incidents. A third resident, R9, fell while attempting to transfer from a wheelchair to bed. The resident was left unattended in their room without a chair alarm, which was supposed to be in place to prevent such incidents. The resident had severe cognitive impairment and was known to attempt self-transfers, necessitating close supervision. The lack of a chair alarm and failure to assist the resident to bed after meals were identified as contributing factors to the fall.
Failure to Supervise Resident with Known Inappropriate Behaviors
Penalty
Summary
The facility failed to protect a resident, identified as R1, from sexual abuse by another resident, R2, who had a known history of inappropriate touching behaviors. R2, who has severe cognitive impairment, was left unsupervised, leading to an incident where R2's hand was found underneath R1's shirt. This incident occurred despite R2's care plan, which documented R2's behaviors and included interventions such as monitoring and removing R2 from situations where inappropriate behaviors were displayed. The facility had previously been cited for a similar incident involving R2 and another resident, R3, where R2 touched R3's breast. Despite this, the facility did not consistently implement one-to-one monitoring for R2, as evidenced by gaps in documentation and staff statements indicating that R2 was often left unsupervised or inadequately monitored. Staff interviews revealed that R2 had multiple incidents of inappropriate touching with other residents, yet the facility's response was insufficient to prevent further occurrences. The facility's failure to adequately supervise R2 and implement effective interventions as outlined in R2's care plan resulted in repeated incidents of inappropriate touching. The lack of consistent one-to-one monitoring and the absence of staff directly supervising areas where R2 was present contributed to the deficiency. The facility's inaction and inadequate response to R2's behaviors allowed the continuation of these incidents, compromising the safety and well-being of other residents.
Removal Plan
- Staff in-services on the Abuse Policy were started and completed. PRN and/or Agency staff will be notified by email with a link to complete abuse training.
- All new hire employees receive the Abuse Policy training through an electronic system and a face-to-face meeting prior to working in the facility.
- R1's Abuse Risk Assessment was completed to reflect R1's recent history of being sexually abused.
- A facility-wide audit was started for all residents identified via the care plan to show potential behaviors that may impede other residents' safety. This audit will continue daily for six weeks.
- The facility abuse policy was reviewed and found to follow state and federal guidelines.
- R2's Care Plan was updated with interventions for one to one monitoring 24 hours per day, not to be around female residents, and prompt intervention when approaching female residents.
- R2 was transferred to the local hospital for evaluation of sexual behaviors and a request for psychiatric evaluation.
- An Emergency Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the deficiency and the facility's action plan.
- The facility completed the Abuse/Neglect Screening assessment for all residents to identify residents at risk for abuse. R1's, R3's, and R7's assessments were revised.
- R2's continual supervision was ongoing prior to the approval of the Abatement plan. R2 remains out of the facility during the survey timeframe and will remain on continual supervision upon return.
- R1, R2, R15, R16's Care plans were reviewed and updated.
Facility Fails to Provide Required Staff Training
Penalty
Summary
The facility failed to ensure that staff were adequately trained in areas identified in its facility assessment, which has the potential to affect all 67 residents residing in the facility. The facility assessment outlined necessary training topics, including effective communication, resident rights, infection control, antibiotic stewardship, and 12 hours of annual in-service training for CNAs, which should include dementia training, identifying changes in condition, and the QAPI program. Upon review, there was no documentation that training on these topics was conducted for all staff within the last year. Despite requests for training documentation on QAPI, infection control, resident rights, communication, dementia, antibiotic stewardship, and change in condition, the facility administrator confirmed that no additional documentation was available.
Lack of Effective Communication Training for Staff
Penalty
Summary
The facility failed to conduct ongoing training in effective resident care communications for all staff, which has the potential to affect all 67 residents residing in the facility. The facility's assessment included effective communication as a staff training topic, but a review of the in-services provided by the Administrator over the past year showed no documentation of such training being conducted. Despite requests for documentation of staff training, including effective communication, the Administrator was unable to provide any additional documentation to confirm that this training had occurred within the last year.
Failure to Conduct Resident Rights Training
Penalty
Summary
The facility failed to conduct ongoing training in Resident Rights for all staff members, which has the potential to affect all 67 residents residing in the facility. The facility's assessment included Resident Rights as a staff training topic, but upon review of the in-services provided by the Administrator, there was no documentation of an all-staff training on Resident Rights conducted in the past year. Despite requests for documentation of staff training, including Resident Rights, the Administrator was unable to provide any additional documentation.
Failure to Conduct QAPI Training for Staff
Penalty
Summary
The facility failed to conduct ongoing staff training on its Quality Assurance Performance Improvement (QAPI) program, which is a required component of staff education as per the facility's assessment. Despite requests for documentation of such training over the past year, the administrator, identified as V1, was unable to provide any evidence that an all-staff training on QAPI had been conducted. This deficiency has the potential to impact all 67 residents currently residing in the facility, as documented in the resident roster dated June 10, 2024.
Failure to Conduct Staff Training on Infection Control Program
Penalty
Summary
The facility failed to conduct ongoing staff training on its Infection Control Program, which is a part of its infection prevention and control program. This deficiency was identified through interviews and record reviews, revealing that the facility did not provide documentation of any all-staff training on the infection control program, standards, policies, and procedures over the past year. The facility's assessment, which includes staff training on infection control, was dated but lacked evidence of implementation. The administrator, identified as V1, was unable to provide additional documentation of staff training when requested on two separate occasions. This failure has the potential to affect all 67 residents residing in the facility, as documented in the resident roster.
Deficiency in CNA Training on Dementia Care
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training, including training on dementia care, as documented in the facility's assessment. This deficiency potentially affects all 67 residents residing in the facility, many of whom have dementia as a common diagnosis. The facility's administrator, V1, acknowledged the lack of a tracking system for CNA training attendance and confirmed that the facility had ceased using electronic training software in June 2023 after a change in corporate ownership. Upon review, it was found that there was no documentation of dementia training or completion of the required 12 hours of in-service training for CNAs V5, V8, V9, V10, and V21. V1 provided a handwritten list of trainings but confirmed that it did not include dementia training or evidence of the required annual training hours. V1 also confirmed that CNAs, including V5, who typically works on the East hallway, assist on other halls as needed, indicating the potential for this deficiency to impact all areas of the facility.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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