Goldwater Care Roseville
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseville, Illinois.
- Location
- 145 S Chamberlain St, Box 770, Roseville, Illinois 61473
- CMS Provider Number
- 146020
- Inspections on file
- 24
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Goldwater Care Roseville during CMS and state inspections, most recent first.
A facility failed to provide a working call system or accessible alternative for all residents after the electronic call system became inoperable. One resident with significant cardiac and mobility issues was admitted without a functioning call light and experienced chest pain for over two hours without staff response, ultimately requiring emergency services. Other residents also lacked access to call lights or bells, and staff were unaware or did not provide alternatives, resulting in unmet care needs and delayed assistance.
Surveyors found that several resident bathrooms and the main dining room vent were not properly cleaned or maintained, with issues such as debris, stained caulking, missing paint, and damaged walls. Residents expressed dissatisfaction with the cleanliness, and staff interviews revealed confusion over cleaning responsibilities. The DON confirmed all residents use the affected dining area, and the Administrator acknowledged the need for repairs.
The facility did not provide required QAPI training to all staff, as confirmed by review of in-service schedules and staff training records, and verified by the DON. This deficiency potentially affected all 40 residents in the facility.
A review of facility records and staff interviews revealed that employees did not receive required training on the Compliance and Ethics Program. The in-service schedule and assessment tools omitted this training, and the DON confirmed that staff had not been trained, affecting all residents in the facility.
The facility did not maintain a working nurse call system in resident bathrooms, leaving several residents—many with significant mobility issues and fall risks—unable to summon assistance during toileting. Residents and staff reported the system had been non-functional for months, leading to delays in care, increased anxiety, and, in one case, a fall with injury. Despite repeated complaints to administration, the deficiency persisted, and alternative measures such as bells were inadequate.
The facility did not maintain a working bathroom nurse call light system, as documented in multiple concern forms and resident council minutes over several months. Observations confirmed that call buttons in several bathrooms failed to activate lights or audible alerts, and both residents and staff reported the system had been down for an extended period. The Maintenance Director and Administrator acknowledged the system's ongoing failure and the lack of available parts for repair, with no clear timeline for replacement.
The facility did not assess the risk of entrapment from side rails for five residents, despite their use for mobility assistance. Observations showed side rails in various positions, and interviews confirmed their use. The administrator acknowledged the lack of documentation for entrapment assessments, indicating a failure to follow policy and ensure resident safety.
A facility failed to conduct a required Level II PASRR evaluation for a resident with suspected schizophrenia, major depression, and anxiety. The resident's PASRR Level I Form indicated the need for a face-to-face Level II evaluation, as required by Federal law, but the medical record lacked documentation of this evaluation. The Regional Operation Manager confirmed the oversight.
A facility failed to assess a resident for the removal of an indwelling urinary catheter after returning from hospitalization. The resident, who was usually continent and used the bathroom with assistance before hospitalization, returned with a catheter but was not consulted about its removal. The DON stated that staff should obtain orders for removal if a catheter was not present before hospitalization, which was not done in this case.
A facility failed to weigh a resident weekly as recommended by a dietitian after a significant weight loss. The resident's weight dropped from 237 to 222 pounds, prompting a recommendation for weekly weights, which was not documented in the medical record after the initial weight loss.
A resident was prescribed Seroquel for mood disorder related to Vascular Dementia without documented behaviors justifying its use. Despite the facility's policy requiring psychotropic drugs only when necessary, the resident showed no aggressive behaviors, and the DON was unsure of antipsychotic regulations.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with Chronic Viral Hepatitis C, as required by their infection control policy. Observations showed no EBP signs or PPE in the resident's room, and the resident confirmed staff only wore gloves during care. Staff interviews revealed a lack of adherence to EBP protocol, despite acknowledging the resident's condition warranted such precautions.
A resident reported verbal and physical abuse by CNAs, including being called 'crazy' and experiencing pain during a transfer. The incidents were reported to the DON, but the facility failed to report the allegations to the State Agency as required by their policy.
A facility failed to investigate allegations of abuse involving a resident and CNAs. The resident reported incidents of verbal and physical mistreatment, which were communicated to the DON but not investigated or reported to the Administrator. Interviews confirmed the interactions, but no immediate action was taken, resulting in a deficiency.
The facility failed to ensure that staff had their hair and facial hair fully restrained during food production and clean-up activities. Multiple staff members, including the Dietary Manager, Cook, Dietary Aide, Dishwasher, and Maintenance Director, were observed with unrestrained hair while engaged in various kitchen activities. This non-compliance with the facility's dress code policy has the potential to affect all 43 residents currently residing in the facility.
The facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions for residents with indwelling urinary catheters, leading to potential spread of MDROs. Staff were observed providing care without necessary PPE, and appropriate signage was not posted, despite documented orders and policies.
The facility failed to provide the required minimum of twelve hours of CNA training over a twelve-month period, affecting all 43 residents. The ADON could not find training records for the past year, except for those from January 2024 forward, which did not meet the twelve-hour requirement, nor did they include dementia care and abuse prevention training.
The facility failed to perform a PASARR level I re-screening for a resident with Bipolar Disorder, Depression, and PTSD. The initial screening was conducted and valid for 90 days, but no subsequent screenings were found in the resident's medical record.
The facility failed to update the care plans for three residents, leading to deficiencies in their care. One resident's care plan did not reflect contact isolation precautions for VRE, another's did not address significant edema, and a third's was not updated to reflect the resolution of a pressure ulcer. These deficiencies were confirmed by facility staff and indicate non-compliance with the facility's care planning policy.
The facility failed to implement fall prevention interventions for three residents. One resident's call light was out of reach, another's chair alarm was non-functional, and a third resident experienced a fall due to inadequate staff assistance during a transfer. These deficiencies highlight lapses in adhering to fall prevention policies.
The facility failed to secure an indwelling urinary catheter for a resident with Neuromuscular Dysfunction of the Bladder. CNAs and the DON confirmed the absence of a securement device, which is against the facility's policy.
The facility failed to develop a dementia care plan for a resident diagnosed with Alzheimer's Dementia. The diagnosis was documented, but the care plan did not address this condition, as confirmed by the Care Plan Coordinator.
The facility failed to ensure a physician evaluated and documented the rationale for the continued use of a PRN psychotropic medication for a resident. The resident had a PRN order for Haldol IM for Anxiety Disorder, but the required physician evaluation and documentation were missing since November 2023, as verified by the Care Plan Coordinator.
The facility failed to implement physician orders for a resident with Type 2 Diabetes Mellitus, as no Hemoglobin A1C tests were documented since the resident's admission. The DON confirmed the oversight and acknowledged the missed monitoring.
The facility failed to provide quarterly financial statements to residents whose personal funds were managed by the facility. Several residents reported not receiving account balance statements for months, and the Administrator in Training confirmed that no financial statements had been issued since the previous year, affecting all 43 residents.
The facility failed to ensure survey results from the past three years were available for review. Several residents were unaware of where to access these results. A binder near the entrance contained outdated information, and the Administrator in Training confirmed it had not been kept current.
Failure to Provide Accessible Call System During Outage
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible to all residents, particularly in bathrooms and bathing areas, after the electronic call system became inoperable. This failure was observed through multiple interviews, record reviews, and direct observations, revealing that several residents, including those with significant medical needs, were left without a functioning call light or an alternative means to summon assistance. One resident, who was admitted with diagnoses including Atrial Fibrillation, repeated falls, heart failure, and morbid obesity, was placed in a bed without a working call system and was not provided with a bell or any alternative device to call for help. The resident experienced chest pain and shortness of breath for over two hours without staff response, ultimately requiring emergency services for a new onset of atrial fibrillation. Other residents were also found to be without working call lights or bells, and staff interviews confirmed that some residents had never been provided with a bell. Residents reported having to rely on roommates or yelling for help, and in some cases, staff were unaware of the inoperability of the call lights. Documentation showed that the facility's call light system had been out of service for an extended period, and there was no documented plan to ensure all residents had access to an alternative call system. The facility's own policy required that all residents have access to a call system at all times, and that defects be promptly reported and addressed, but these procedures were not followed. The lack of a functioning call system affected all 40 residents in the facility, with specific incidents of delayed care and unaddressed needs, including a resident who was left in soiled clothing for hours and another who was unable to call for help during a medical emergency. Staff interviews revealed confusion and lack of communication regarding the status of the call system and the provision of alternative devices. Maintenance records did not reflect timely reporting or repair of the call system failures, and care plans were not updated to reflect the need for increased supervision or alternative call systems during the outage.
Removal Plan
- All resident care plans were updated to ensure residents receive frequent rounding to ensure needs are met and bells are within reach if a call light is found to be inoperable. Staff will complete a work order and submit to the Maintenance Department for service or repairs. The Maintenance Director will keep all work orders which will document what type of repair was conducted. The Administrator and/or Director of Nursing will be responsible for overseeing and maintaining plan until call light system is back online and operating appropriately.
- All staff were in-serviced on the facility's Call Light policy including reporting call bell system defects promptly to the Maintenance Department for servicing and checking rooms frequently until the call light system is repaired, providing dependent residents with a hand bell whenever a call light is found to be inoperable, and answering call lights promptly.
- V2 was educated on the facility's Comprehensive Care Plan policy, including developing a comprehensive care plan after completion of the comprehensive assessment that includes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, resident's goals for admission and desired outcomes, resident's preference and potential for future discharge, including the resident's desire to return to the community and any referrals to local contact agencies.
- V6 (Maintenance Director) was educated to document when call lights were out of service, when repairs were made, and to keep a service repair/work order binder to document when call lights are out of service and when repairs are made.
- All resident bathrooms were provided with hand bells.
- Daily audits were completed to ensure all call lights were operational and hand bells were within reach of all residents that did not have working call lights with the exception of 300 hall which closed and does not currently have residents. These audits will continue.
- All staff were re-in serviced on ensuring V17 receives a work order whenever call lights are not working and ensuring V17 documents in the maintenance binder when the call lights are inoperable and are repaired.
- The new call system was fully operational and working on all of 100 and 200 hallway bathrooms and resident rooms. All resident rooms and bathrooms had bells as back up call devices. These bells were within reach of all residents.
Failure to Maintain Clean and Safe Resident and Common Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment for its residents. During a facility tour, multiple resident bathrooms were found with significant maintenance and cleanliness issues, including cove base pulled away from the wall, missing chunks of drywall with debris on the floor, stained caulking around toilets, and bathroom walls with missing paint. Additionally, air conditioner vents in resident bathrooms were covered in debris. The main dining room's large heating/cooling vent was completely covered in thick, brown debris. These conditions were confirmed by the facility's Administrator during a follow-up tour. Interviews with residents revealed dissatisfaction with the cleanliness and maintenance of their bathrooms, with one resident expressing concern about the air quality due to a dirty vent, particularly given their asthma. Staff interviews indicated a lack of clarity regarding responsibility for cleaning the dining room vent, with both housekeeping and maintenance staff stating they had never cleaned it. The Director of Nursing confirmed that all residents, including those with special feeding needs, use the main dining room. The Administrator acknowledged awareness of the need for repairs and updates in many resident bathrooms.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all employees, as required by its own Facility Assessment Tool. A review of the facility's census confirmed that 40 residents were present at the time of the deficiency. Examination of the Annual In-Service Schedule and staff in-service records from 9/1/24 through 9/6/25 revealed that QAPI training was not included. This was further verified by the Director of Nursing, who confirmed that staff had not received QAPI training.
Lack of Staff Training on Compliance and Ethics Program
Penalty
Summary
The facility failed to provide training on its Compliance and Ethics Program to all employees, as evidenced by a review of records and staff interviews. The Annual In-Service Schedule did not include any sessions related to the Compliance and Ethics Program, and the Facility Assessment Tool did not list this program as a required staff training. Additionally, a review of staff in-service records over a one-year period confirmed the absence of such training. This was further verified by the DON, who acknowledged that staff had not received training on the Compliance and Ethics Program. The facility census at the time documented 40 residents residing in the facility.
Failure to Maintain Functioning Nurse Call System in Resident Bathrooms
Penalty
Summary
The facility failed to provide a functioning nurse call system in resident bathrooms and bathing areas for all residents, as required by facility policy. Observations, interviews, and record reviews revealed that the nurse call system in resident bathrooms had been non-functional for an extended period. Multiple residents reported that the system had been down for months, and staff confirmed ongoing issues with the system despite attempts at repair. In several instances, activating the call system in resident bathrooms did not result in any visual or audible alert at the room door or nurse's station, and this was verified by both nursing and maintenance staff. Four residents with significant medical conditions and varying levels of dependence for toileting were directly affected by the non-functioning call system. These residents included individuals with diagnoses such as hemiplegia, chronic pain, osteoarthritis, diabetes with neuropathy, and a history of falls. Each resident's care plan emphasized the need for prompt response to call lights and the importance of having the call system within reach, especially given their fall risk and dependence on staff for toileting assistance. Despite these documented needs, residents were left without a reliable means to summon help while in the bathroom. Residents described experiencing fear, anxiety, and in some cases, actual harm due to the inability to call for assistance. One resident reported waiting up to 30 minutes for help after being left on the toilet, while another described falling in the bathroom and being unable to reach the provided bell or call for help, resulting in injury and a subsequent emergency room visit. Staff and residents both reported that complaints about the broken system had been made to the facility administrator over several months, but the issue remained unresolved at the time of the survey.
Failure to Maintain Functioning Bathroom Nurse Call Light System
Penalty
Summary
The facility failed to provide a functioning bathroom nurse call light system for its residents. Multiple facility documents, including Concern Forms and Resident Council Minutes from March through June, documented ongoing issues with non-functioning call lights. Observations on June 2nd confirmed that the nurse call buttons in several residents' bathrooms did not activate lights or audible alerts, either outside the rooms or at the nurse's stations. Residents reported that they had complained about the broken system for months, and staff, including an LPN and CNA, confirmed that the bathroom nurse call system had been down for an extended period. The Maintenance Director stated that the system had been inoperable since he began employment in February and that repeated repair attempts by a local company were unsuccessful due to the outdated nature of the system and lack of available parts. The Administrator confirmed that the system had been down since at least early January, that corporate staff were notified in January, and that bids for a replacement system were obtained in May, but there was no information on when the system would be replaced or operational. At the time of the report, 44 residents resided in the facility.
Failure to Assess Entrapment Risk with Bed Rails
Penalty
Summary
The facility failed to assess the risk of entrapment from side rails for five residents out of thirteen reviewed for siderails, within a total sample of 28 residents. The facility's policy requires an assessment for safety risks before installing bed rails, including checking compatibility with the bed frame and mattress, ensuring proper installation, and regularly inspecting for potential entrapment areas. However, the facility did not document any entrapment risk assessments for the residents in question, despite their use of side rails for mobility assistance and positioning. Observations revealed that the residents' beds had side rails in various positions, and interviews confirmed that the residents used these rails for assistance. The facility's administrator acknowledged the lack of documentation for entrapment assessments for these residents and mentioned ongoing training for the new Maintenance Director regarding these assessments. The absence of documented assessments indicates a failure to adhere to the facility's policy and ensure resident safety concerning the use of side rails.
Failure to Conduct Required Level II PASRR Evaluation
Penalty
Summary
The facility failed to obtain a Level Two PASRR (Preadmission Screening and Resident Review) for a resident who was identified as needing further evaluation. The resident's PASRR Level I Form, dated August 1, 2023, indicated that the resident had never undergone a PASRR Level I screen before and documented mental health diagnoses including suspected schizophrenia, current major depression, and current anxiety. The PASRR Level I screen concluded that a face-to-face Level II evaluation was required, as mandated by Federal law, due to the potential presence of a serious mental illness or an intellectual/developmental disability. However, the resident's medical record lacked any documentation of a completed Level II PASRR evaluation. This oversight was confirmed by the Regional Operation Manager, who acknowledged the absence of the necessary documentation and indicated that the evaluation had been missed.
Failure to Assess Indwelling Urinary Catheter Removal
Penalty
Summary
The facility failed to assess a resident, identified as R45, for the removal of an indwelling urinary catheter. R45 was admitted to the facility with several diagnoses, including unspecified diastolic congestive heart failure and chronic kidney disease. Initially, R45 was usually continent and required assistance to use the bathroom. However, after a hospitalization for sepsis, upper respiratory infection, and hypoxia, R45 returned to the facility with an indwelling urinary catheter. Despite this change, there was no documentation in R45's electronic medical record regarding any discussions about the necessity or potential removal of the catheter. Observations and interviews revealed that R45 was unaware of the reason for the catheter and had not been consulted about its removal. A Certified Nursing Assistant confirmed that R45 did not have a catheter before the hospitalization and used the bathroom with assistance. The Director of Nursing stated that it is expected for nursing staff to obtain orders for catheter removal if a resident returns from the hospital with a catheter they did not have before. This expectation was not met, leading to the deficiency noted in the report.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to adhere to its dietary policy by not weighing a resident as recommended, which led to a deficiency. The policy stated that residents identified at nutritional risk should be weighed weekly or bi-weekly as per physician order or Interdisciplinary Team recommendation. A resident's medical record documented a weight of 237 pounds on January 9, 2025, and a subsequent weight of 222 pounds on February 11, 2025, indicating a 6.3% weight loss in one month. Following this, a dietitian recommended weekly weights for four weeks due to the weight loss. However, the resident's medical record did not contain any documentation of weights after February 11, 2025. On March 5, 2025, the Dietary Manager confirmed the absence of any weight documentation after the specified date, despite the dietitian's recommendation.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to provide an appropriate indication for the use of antipsychotic medication for one resident, identified as R47, who was part of a sample of 28 residents reviewed for unnecessary medications. R47 was admitted to the facility with multiple diagnoses, including Vascular Dementia with Mood Disturbance. Despite having a physician's order for Seroquel, an antipsychotic medication, to be administered daily for mood disorder related to Vascular Dementia, there was no documented evidence of behaviors that would necessitate the continued use of this medication. Observations and interviews revealed that R47 exhibited no aggressive behaviors towards others and had not shown any documented behaviors in the electronic medical record for the past month. The facility's policy on psychotropic medication requires that such drugs are only given when necessary to treat a specific condition and at the lowest therapeutic dose. However, the Director of Nursing was unsure of the regulations regarding antipsychotic medications, and the Licensed Practical Nurse confirmed that R47 had not displayed aggressive behaviors for some time. This lack of documented behavioral symptoms and the absence of a clear indication for the continued use of Seroquel suggest a failure to adhere to the facility's policy and regulatory standards for the use of psychotropic medications.
Failure to Implement Enhanced Barrier Precautions for Resident with Hepatitis C
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident diagnosed with Chronic Viral Hepatitis C, as required by their infection prevention and control program. The facility's policy mandates the use of EBP, which includes the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that there were no EBP signs or Personal Protective Equipment (PPE) available outside or inside the resident's room. The resident confirmed that staff only wore gloves during care and had never seen them wear a gown. Interviews with facility staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, indicated a lack of adherence to the EBP protocol. Both staff members acknowledged that the resident's condition warranted the use of EBP, yet confirmed that the necessary precautions were not in place. The Assistant Director of Nursing verified that the resident should have been on EBP due to the infection risk posed by Hepatitis C, but acknowledged that the protocol was not being followed for this resident.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report alleged verbal, mental, and physical abuse of a resident to the State Agency as required by their policy. The policy mandates that any allegation of abuse be reported to the Department of Public Health immediately, but not more than two hours after the allegation. A resident, identified as R3, reported two incidents involving CNAs. In the first incident, a CNA was loud and called the resident 'crazy' when asked to be quiet. In the second incident, another CNA caused the resident pain while using a mechanical lift and subsequently denied causing harm, again calling the resident 'crazy.' The resident reported these incidents to the Director of Nursing, but the allegations were not documented or reported to the State Agency as required. The Director of Nursing confirmed that the allegations were not reported, and the facility was unable to provide documentation of any report being made.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse and ensure the protection of a resident during the investigation. A resident, identified as R3, reported two separate incidents involving CNAs V5 and V6. In the first incident, R3 stated that V6 was loud and called her crazy when she asked for quiet. In the second incident, R3 reported that V5 caused her pain while using a mechanical lift and subsequently called her crazy. R3 communicated these concerns to the Director of Nursing (DON), V2, who acknowledged the reports but did not conduct an investigation or report the incidents to the Administrator, V1. Interviews with the involved staff, V5 and V6, confirmed the interactions with R3 but did not result in any immediate action or investigation. V5 and V6 both stated they worked throughout the building and did not remain in one hall, which could have implications for monitoring and supervision. V2 admitted to not investigating R3's allegations and failing to report them to V1, who was aware of the incident involving V6 but did not initiate an investigation. This lack of action and failure to follow the facility's abuse prevention policy resulted in a deficiency in addressing and investigating potential abuse allegations.
Failure to Restrain Hair and Facial Hair in Kitchen
Penalty
Summary
The facility failed to ensure that staff had their hair and facial hair fully restrained during food production and clean-up activities. This was observed on multiple staff members, including the Dietary Manager, Cook, Dietary Aide, Dishwasher, and Maintenance Director. Specifically, the Cook, Dietary Aide, and Dietary Manager had large strands of hair unrestrained on the tops, sides, and backs of their heads. The Dishwasher wore a ball cap that left the sides and back of his hair unrestrained and had no restraint covering his beard. Similarly, the Maintenance Director wore a ball cap that left the front, sides, and back of his hair unrestrained and had no restraint covering his beard. These observations were made while the staff were engaged in various kitchen activities, including cooking, stacking clean plates and cups, washing dishes, and removing screens above the stove. The facility's policy, revised in October 2016, mandates that all food service employees adhere to a dress code that includes hair nets or appropriate hair coverings, including facial hair coverings, while involved in food production and clean-up activities. The Dietary Manager confirmed that all staff should have their hair fully restrained while in the facility kitchen. This failure to comply with the facility's dress code policy has the potential to affect all 43 residents currently residing in the facility.
Failure to Implement Isolation and Barrier Precautions
Penalty
Summary
The facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions to contain the potential spread of Multi Drug-Resistant Organisms (MDROs). This failure was observed in multiple instances involving residents with indwelling urinary catheters, which are high-contact care activities requiring enhanced precautions. Specifically, the facility did not post appropriate signage or provide necessary Personal Protective Equipment (PPE) for staff when caring for these residents, despite documented orders and policies requiring such measures. One resident with a urinary catheter and a confirmed case of Vancomycin Resistant Enterococcus (VRE) did not have isolation signage or PPE available at the entrance to his room. Staff members were observed providing care without wearing gowns, contrary to the facility's Contact Precautions policy. The resident's room lacked the necessary postings and PPE from the time the VRE was identified until the surveyor's visit, despite the resident being on contact isolation precautions. Another resident with an indwelling urinary catheter also did not have Enhanced Barrier Precautions signage or PPE available. Staff confirmed that no residents were on Enhanced Barrier Precautions, despite the resident's care plan and physician's orders indicating the need for such precautions. Similar deficiencies were noted with other residents requiring catheter care, where staff were observed providing care without the required PPE and without appropriate signage indicating isolation precautions.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to provide the required minimum of twelve hours of nurse aide training over a twelve-month period, which has the potential to affect all 43 residents in the facility. The Certified Nursing Assistant (CNA) training folder, provided by the Assistant Director of Nursing (ADON), did not contain the required training documentation for the past year for CNAs currently working in the facility. During an interview, the ADON stated that they could not find any CNA training records for the last year, except for those from January 2024 forward, which did not meet the twelve-hour requirement. Additionally, there was no proof that all CNAs received training in dementia care and abuse prevention.
Failure to Perform PASARR Level I Re-Screening
Penalty
Summary
The facility failed to perform a PASARR (Pre-Admission Screening and Resident Review) level I re-screening for one of two residents reviewed for PASARR screening. The resident, identified as R4, was admitted with diagnoses including Bipolar Disorder, Depression, and Post-Traumatic Stress Disorder. The initial OBRA-I screen was conducted on 01/20/20 and was valid for 90 days. However, the current medical record for R4 did not include any subsequent PASARR screenings. The Administrator in Training confirmed that no additional screenings beyond the initial OBRA-I screen were available for R4.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for three residents, leading to deficiencies in their care. Resident R4 had a urine specimen that tested positive for Vancomycin Resistant Enterococcus (VRE) and was on contact isolation precautions. However, R4's care plan did not reflect this status. This was confirmed by the Licensed Practical Nurse/Care Plan Coordinator. Resident R32 had significant edema in the bilateral lower legs and was prescribed Lasix for the condition, but the care plan did not address the edema. This omission was also verified by the Care Plan Coordinator. Resident R35 had a previously documented stage 2 pressure ulcer on the right gluteal fold, which had resolved by the time of the survey. However, the care plan had not been updated to reflect the resolution of the skin issue, as confirmed by the Director of Nurses. The facility's policy on Comprehensive Care Planning mandates that care plans be reviewed and revised as necessary to reflect the resident's current medical, nursing, and psychological needs. The failure to update the care plans for these residents indicates non-compliance with this policy. The deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in the facility's adherence to its own care planning procedures. These lapses could potentially impact the quality of care provided to the residents, as their care plans did not accurately reflect their current medical conditions and required interventions.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to reduce the risk of falls for three residents. Resident R32, who has diagnoses including Alzheimer's Disease and is at high risk for falls, was found without a call light within reach, which was on the floor under the bed. This was confirmed by a Registered Nurse. Resident R41, diagnosed with Dementia and other conditions, was found in a wheelchair with a non-functioning chair alarm that was not connected to a power source, as verified by a Registered Nurse. Resident R23, who requires substantial assistance for mobility and has a high fall risk, experienced a fall while being assisted to bed. The fall occurred when the resident leaned forward and fell to her knees. The incident was witnessed by a CNA who was the only staff member present, contrary to the facility's policy requiring two staff members for lift assistance. The Assistant Director of Nursing confirmed the lack of a witness statement and the Director of Nursing acknowledged the policy breach. These deficiencies highlight the facility's failure to adhere to its fall prevention policies, including ensuring call lights are within reach, maintaining functional alarm systems, and providing adequate staff assistance during transfers. These lapses contributed to the increased risk of falls and potential harm to the residents involved.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was secured with a securement device for a resident diagnosed with Neuromuscular Dysfunction of the Bladder. During an observation, the resident's catheter was found unsecured while she was lying in bed. Certified Nursing Assistants confirmed the absence of a securement device and acknowledged that the catheter should have been secured. The Director of Nursing also confirmed that all indwelling urinary catheters should be secured with a securement device, as per the facility's policy.
Failure to Develop Dementia Care Plan
Penalty
Summary
The facility failed to develop a dementia care plan for a resident diagnosed with Alzheimer's Dementia. The resident's electronic diagnoses dated 3/6/24 documented the diagnosis, but the current care plan dated 2/28/24 did not include a comprehensive care plan addressing this condition. This deficiency was confirmed by the Care Plan Coordinator on 4/17/24.
Failure to Document Physician Evaluation for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the physician evaluated and documented the rationale for the continued use of a PRN psychotropic medication for one resident. The facility's policy requires that residents must not have PRN orders for psychotropic medications unless necessary to treat a diagnosed specific condition, and PRN orders for antipsychotic medications are limited to 14 days unless re-evaluated by the physician. Resident R24 had a physician order for Haldol IM every 12 hours as needed for Anxiety Disorder, dated 3/8/24, with a second clarification order dated 3/15/24. However, the resident's chart lacked any physician visit notes after 11/16/2023, indicating that the required evaluation and documentation for the continued use of the antipsychotic medication were missing. This was verified by the Care Plan Coordinator on 4/17/24, who confirmed that R24 had not been seen by her physician since November 2023.
Failure to Implement Physician Orders for Laboratory Tests
Penalty
Summary
The facility failed to ensure physician orders were implemented for laboratory tests for a resident reviewed for Insulin. The resident had a physician's order for Insulin Glargine to be injected subcutaneously twice a day for Type 2 Diabetes Mellitus without complications. Additionally, there was an order for Hemoglobin A1C to be conducted every three months. However, the resident's medical record did not document any Hemoglobin A1C results since their admission to the facility on 7/12/23. The Director of Nursing confirmed that a Hemoglobin A1C test had not been completed for the resident since admission, acknowledging that it was missed and should have been monitored.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide quarterly financial statements to residents whose personal funds were managed by the facility. According to the facility's Resident Right Manual, residents are entitled to receive a current, itemized written statement of their financial records at least once every three months. However, during a group meeting, several residents reported that they had not received any account balance statements for several months. One resident mentioned that it took two weeks to get information about their balance, which required the facility staff to contact the corporate office. This indicates a significant delay and lack of transparency in managing residents' funds. The Administrator in Training (V1) confirmed that the facility had not been providing the required quarterly financial statements. V1 admitted to not being aware of the necessity to keep these statements current manually. The facility manages funds for all 43 residents, and none of them had received a financial statement since the previous year. This lapse in providing financial statements affects all residents currently residing in the facility, as verified by the Center for Medicare and Medicaid Services Form 671.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that the results of surveys, certifications, and complaint investigations conducted during the past three years were available for review. During a group meeting with residents who have previously attended Resident Council meetings, several residents did not know where to access the facility's previous annual and complaint survey results and were unaware that all State Agency survey results were accessible. A binder titled 'Certification Survey Results for Public Inspection' was found near the entrance to the building, but it only contained the most recent survey results from a complaint investigation conducted on 01/18/2023. The Administrator in Training confirmed that the binder had not been kept current and that the facility's 2023 annual survey and additional complaint investigations conducted after 01/18/2023 were not included.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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