Haven Of Champaign
Inspection history, citations, penalties and survey trends for this long-term care facility in Champaign, Illinois.
- Location
- 1315 Curt Drive, Suite B, Champaign, Illinois 61821
- CMS Provider Number
- 146017
- Inspections on file
- 39
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Haven Of Champaign during CMS and state inspections, most recent first.
The facility did not provide RN coverage for at least eight consecutive hours on one day, as required, when the scheduled RN called off and the DON did not cover the shift. This affected all 50 residents present in the facility.
A resident with multiple chronic conditions experienced increased pain and swelling after a fall from a sit-to-stand lift, which limited her ability to perform daily activities and participate in social events. Despite physician orders for increased pain medication and a care plan addressing pain management, the facility did not effectively manage her pain according to these directives or the resident's preferences, resulting in a decline in her functional abilities.
A resident with significant physical debility and hand weakness was transferred by a CNA using a sit-to-stand mechanical lift without the required safety belt and without a second staff member present. The resident, unable to maintain her grip, fell during the transfer. Facility policy mandates two trained staff and use of the safety belt for such transfers, but these protocols were not followed.
A resident with multiple chronic conditions and recent injury did not receive her physician-ordered Norco for several days because the facility failed to maintain an adequate supply. The resident reported ongoing pain, and staff confirmed the medication had run out and was not reordered in time, resulting in a lapse in pain management.
The facility failed to respect residents' dignity and ensure timely response to call lights, leading to distress among residents. Incidents included staff dismissing residents' requests, leaving a resident on the floor for over an hour, and causing emotional distress through rude behavior. Despite documented concerns, the Administrator was unaware of specific issues, indicating a lack of communication and follow-up.
The facility failed to follow up on and document actions for grievances reported by residents, affecting all 51 residents. Despite policies requiring documentation and resolution of grievances, the facility's Grievance Log only recorded a few follow-up actions. Residents reported ongoing issues with call light wait times, late medications, and missing items, and were unsure of the grievance process. Staff confirmed medication administration delays and acknowledged repeated issues without proper documentation of follow-up actions.
The facility did not employ a full-time DON and failed to provide RN services for eight consecutive hours daily. This issue persisted over several days, with the facility lacking RN coverage on specific dates. The absence of a full-time DON since early February was confirmed by the Assistant DON and the Administrator.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 51 residents. The Dietary Manager, supervising dietary operations, lacks a valid Food Safety/Dietary Manager Certificate, which expired over a year ago. The facility's assessment requires a full-time dietician or qualified nutrition professional for daily and emergency support.
The facility failed to ensure that dietary aides had the necessary training and food handler's certificates, as required by Illinois law, potentially affecting all 51 residents. Observations showed aides preparing and distributing meals without proper certification, confirmed by the Dietary Manager and acknowledged by the Administrator.
The facility failed to annually implement and evaluate a performance improvement plan, affecting all 51 residents. The QAPI Plan requires annual self-assessment and prioritization of activities, but there was no evidence of follow-up or evaluation of interventions in the PIPs for skin care and showers. The administrator, new to the role, could not find documentation of implementation or evaluation, citing the former administrator's practice of discarding records.
The facility did not hold the required quarterly Quality Assurance meetings, as outlined in their QAPI Plan, since the current Administrator's tenure began. Only one meeting was conducted in January 2025, with missing meetings in the previous year, potentially affecting all 51 residents.
The facility failed to implement its water management plan and infection control policies, affecting all residents. The Maintenance Director did not perform necessary water checks, and an LPN improperly cleaned a resident's pressure wound. Additionally, there was a lack of Enhanced Barrier Precautions (EBP) signage and PPE for residents with catheters, and staff were not adequately trained on EBP, leading to improper use of protective equipment.
The facility failed to ensure residents' access to personal funds, as four residents reported being unable to obtain money on weekends when the Business Office Manager was absent. The facility's policy allows fund access during business hours, but no alternative arrangements were made for weekends, leading to the deficiency.
The facility did not provide quarterly statements for personal fund accounts to several residents, as required by their policy. Following a change of ownership, the Business Office Manager confirmed that statements had not been distributed, affecting residents with personal fund accounts and balances ranging from $381.00 to $5,199.75.
The facility failed to provide scheduled showers for two residents who required assistance with activities of daily living. One resident, with severe cognitive impairment, did not receive any documented showers over two months, while another resident on hospice care received fewer showers than scheduled over three months. The facility's policy requires documentation of all shower-related activities, including refusals and bed baths, which was not adhered to in these cases.
The facility failed to provide immunization education, obtain consent, and administer vaccinations for five residents. There was no documentation in their medical records regarding education, consent, or administration of vaccines. The Corporate Nurse confirmed the lack of documentation, despite the facility's policy requiring the offering of immunizations unless contraindicated.
A resident was found with a Combivent inhaler at their bedside, which they self-administered without a physician's order. The facility's policy requires a physician's order for medications to be kept at the bedside, but the resident's records did not document such an order. A nurse confirmed the absence of the order, and the ADON stated that an assessment and physician's order are necessary for self-administration of medications.
A facility failed to implement physician-ordered treatments and monitoring for a resident with lymphedema and CHF. The resident's leg wraps were not consistently applied and removed as ordered, and their care plan lacked specific interventions for their conditions. Weight monitoring was inconsistent, with significant weight gains not reported to the physician. Staff acknowledged the lack of documentation and adherence to orders, contributing to the deficiency.
A facility failed to obtain a treatment order and monitor a newly discovered pressure ulcer for a resident with multiple health conditions. The resident's medical record lacked documentation of the pressure wound, and treatment was delayed. An LPN improperly applied a Calcium Alginate dressing, covering unaffected skin. The facility's policy on pressure wound prevention was not followed.
The facility failed to provide adequate catheter care for two residents, leading to deficiencies in hygiene and documentation. One resident's catheter tubing was observed dragging on the floor, and the drainage bag was touching the floor. The CNA did not clean the resident's labia/perineal area as required. Another resident received inadequate catheter care from a CNA who reused the same area of the wipe multiple times. These deficiencies highlight lapses in the facility's adherence to proper catheter care protocols.
Two residents experienced medication administration errors, leading to a 7.14% error rate. An LPN failed to check a resident's blood pressure before administering Lisinopril, and another resident swallowed Zofran whole instead of allowing it to dissolve under the tongue. These actions deviated from physician orders and manufacturer recommendations.
A resident in hospice care did not receive the prescribed thickened liquids due to a failure in updating the diet order in the facility's records. Despite the resident's need for thickened liquids to manage coughing and congestion, meal trays contained regular consistency liquids. The oversight was confirmed by CNAs and dietary staff, revealing a lapse in communication and documentation of the diet order.
The facility did not have an RN on duty for eight consecutive hours on two occasions due to staff illness, affecting 46 residents. The Director of Nursing confirmed the absence of RN coverage, as both the DON and another RN were out sick with COVID-19.
The facility experienced significant delays in meal service due to inadequate dietary staffing, affecting several residents. During a COVID-19 outbreak, kitchen staff shortages resulted in breakfast being served as late as 11:00 AM, with lunch and supper also delayed. Staff, including an LPN and the Social Services Director, confirmed the delays and the need for additional help in the kitchen. The dietary manager, new to the role, acknowledged the staffing issues and noted improvements were underway.
The facility failed to maintain a clean and sanitary kitchen, potentially affecting all 46 residents. Observations revealed dust, debris, and dirt buildup around the range and prep table, with dried splatters on nearby surfaces. The Dietary Aide confirmed that cleaning tasks were not completed as required, and the Dietary Manager lacked a cleaning log or schedule, despite the facility's Cleaning Schedule mandates.
During a COVID-19 outbreak, the facility failed to maintain an adequate supply of N95 respirators and ensure staff wore appropriate PPE. Staff were observed wearing KN90 and KN95 masks, which were not changed between COVID-19 positive and negative rooms, and masks were often worn incorrectly. Housekeeping practices were insufficient, with high-touch surfaces disinfected only every other day, contributing to the spread of the virus among all 46 residents.
The facility failed to maintain functioning call lights for four residents, resulting in significant delays in staff response. Residents, including those with cognitive impairments and incontinence, were forced to use handheld bells, leading to prolonged waits for assistance. Staff confirmed the call lights had been non-functional for weeks, and the administrator cited budget constraints as a barrier to repairs.
The facility failed to maintain a clean and homelike environment due to insufficient housekeeping staff, affecting three residents. Residents reported that their rooms were not cleaned daily, with observations of sticky floors, overflowing garbage, and unclean bathrooms. The facility's housekeeping schedule showed gaps in staffing, and the Housekeeping Supervisor confirmed that laundry staff had to cover housekeeping duties when staff were out sick, impacting the daily cleaning routine.
A resident, dependent on staff for bathing, did not receive scheduled showers for two weeks during a COVID-19 outbreak at the facility. The resident, who is cognitively intact, prefers weekly showers but was last given a shower at the beginning of the month. A staffing shortage due to the outbreak was confirmed by a Registered Nurse, and the Certified Nursing Assistant responsible for showers verified the missed schedule.
A resident with Type 2 Diabetes Mellitus was not provided with the physician-ordered Controlled Carbohydrate diet. Instead, the resident received a regular diet meal, including items not suitable for their condition. The error was due to an oversight on the Diet Order Form, where the Controlled Carbohydrate diet was not marked, leading to incorrect meal tray documentation.
The facility failed to employ a clinically qualified Director of Food and Nutrition, affecting all 49 residents. The dietary schedule showed no dietary manager until late July, and the Administrator had been cooking due to staff shortages. A new dietary manager was hired, but there was no documentation of her certification or credentials.
The facility failed to provide adequate staffing in the dietary department, resulting in delayed meal services for residents. The administrator and DON had to step in to cook due to a lack of trained staff, causing residents to experience significant delays in receiving meals. The dietary manager was overworked, leading to an absence, and a staff member exhibited stress-related behavior towards a resident.
Two residents were subjected to verbal and mental abuse by a cook in the facility. The cook yelled at a severely cognitively impaired resident, threatened to stop serving dinner, and made the resident eat last. A CNA intervened to prevent physical harm. Another resident witnessed the incident and reported it to the Resident Care Coordinator. The facility's policy on abuse prevention was not adhered to, leading to this deficiency.
The facility failed to follow its abuse prevention policy when a cook allegedly threatened a resident during a meal. A CNA witnessed the incident but did not report it immediately, allowing the cook to leave the facility without being removed from resident contact. The incident was later reported by the Resident Care Coordinator to the DON and Administrator.
The facility failed to employ a clinically qualified Director of Food and Nutrition, affecting all 47 residents. The Administrator and DON have been covering cooking duties after the previous Dietary Manager left after five days. The facility's job summary requires a qualified individual to manage food services, but no such person was present during the survey.
The facility failed to ensure that dietary aides and a cook were qualified, affecting all 47 residents. The facility's assessment required food and nutrition services staff to be present for 14 hours daily, but the dietary aides and cook lacked necessary certifications. Interviews with the DON and Administrator confirmed the absence of required cooking/sanitation and food handler's certificates. The cook, employed for over a week, was unaware of the certification requirement until the survey.
A facility failed to administer a dietary supplement as ordered for a resident with TIA and Cerebral Infarction. The resident's Physician Order Sheet required Med Pass 2.0 Supplement twice daily, but records show it was not given on multiple occasions. The DON confirmed the omissions, despite the care plan and facility policy requiring adherence to physician orders.
A resident with multiple diagnoses, including Depression and PTSD, reported being verbally abused by a CNA who raised her voice, yelled, and cursed when the resident requested hot chocolate. The incident left the resident feeling embarrassed and humiliated. The CNA was terminated following an investigation.
The facility failed to provide sufficient RN hours on four days, potentially affecting all 49 residents. Nursing schedules showed only four hours of RN coverage on three days and no RN coverage on one day. This was confirmed by the Resident Care Coordinator.
The facility failed to maintain a sanitary range hood and did not ensure adequate chlorine levels in the commercial dishwasher, potentially affecting the cleanliness of dishware and utensils used by 49 residents.
The facility failed to conduct quarterly QA meetings as required, with only one documented meeting in the past year. This was confirmed by the Administrator and Regional Support. The facility's policy mandates quarterly meetings, and at the time of the survey, the facility had 49 residents.
The facility failed to answer call lights in a timely manner for seven residents and did not provide privacy while administering an insulin injection to a resident in the dining room. Multiple residents confirmed the delays, and an LPN stated that administering insulin in the dining room was the usual practice.
The facility failed to label insulin pens after opening for five residents, contrary to their policy. An LPN incorrectly identified delivery dates as the opening dates, and another LPN confirmed the pens should be dated when opened, as per the facility's policy.
The facility failed to ensure that food served was palatable and attractive, affecting multiple residents. Residents reported that the food was terrible, unappetizing, and often served at incorrect temperatures. Observations confirmed uneaten lunch plates with hard and cold carrots, which residents found inedible.
The facility failed to provide a resident with an Advance Beneficiary Notice (ABN) at the termination of a Medicare Part A covered stay, nullifying the resident's right to continue therapy services at their own expense or decline therapy services. The Business Office Manager acknowledged the oversight.
The facility failed to report and investigate injuries of unknown origin for a resident and a resident-to-resident incident involving two residents. The staff did not notify the Administrator, leading to a lack of investigation and documentation, which is against the facility's Abuse Prevention Program Policy.
The facility failed to complete comprehensive MDS assessments within the required time frames for two residents. Both residents had their Care Area Assessments and Care Plan Completion signed well beyond the mandated 14-day period for MDS completion and the additional 7 days for Care Plan Completion.
The facility failed to encode and transmit residents' MDS Assessments within the required time frame, affecting two residents. The MDS completion dates were significantly delayed beyond the 21-day transmission requirement set by the Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual.
The facility failed to accurately encode MDS for two residents, incorrectly documenting a stage 3 pressure ulcer for one resident and a feeding tube for another. Medical records and staff interviews did not support these entries.
The facility failed to obtain a Level 2 PASARR for a resident diagnosed with severe mental illness (SMI). The resident's Level 1 PASARR indicated no SMI, but records showed diagnoses of schizophrenia and psychosis. The Business Office Manager suggested the hospital might not have included the mental illness diagnosis before the resident's transfer.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required. Review of the facility's daily assignment sheets showed that there was no RN coverage on December 25, 2025. The Director of Nursing confirmed that the RN scheduled for that day called off and the Director did not come in to cover the shift. The facility assessment indicated that staffing would be based on resident needs and required guidelines, and the room roster documented that 50 residents were residing in the facility at the time of the deficiency. This lapse in RN coverage was confirmed through interview and record review, and it was acknowledged by the Director of Nursing that the required RN presence was not maintained for the specified period.
Failure to Provide Effective Pain Management Following Resident Injury
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple medical conditions, including generalized weakness, polyarthralgia, lymphedema, obesity, gout, physical debility, osteoarthritis, hypertension, and diabetes. After a fall from a sit-to-stand lift, the resident experienced increased pain and swelling in her left hand and knee, which significantly limited her ability to perform daily activities such as getting out of bed, propelling her wheelchair, and participating in social and religious activities. Observations confirmed visible swelling and limited mobility in the resident's left hand and knee, and the resident reported ongoing pain that interfered with her independence and comfort. Nursing notes did not document the fall incident but indicated that the resident began complaining of excessive pain following the event and subsequently refused to get out of bed. The resident was sent to the emergency room for evaluation and later admitted to the hospital for pain management, where her pain medication was increased. Upon return to the facility, physician orders reflected an increased frequency for pain medication administration, and the care plan noted the need for pain assessment and medication as ordered. Despite these orders, the facility did not effectively manage the resident's pain according to physician instructions, the care plan, or the resident's preferences, resulting in a decline in her ability to participate in routine activities of daily living.
Unsafe Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a sit-to-stand mechanical lift without following established safety protocols. The resident, who had multiple medical conditions including generalized weakness, lymphedema, obesity, gout, osteoarthritis, and physical debility, was unable to fully grip the lift's grab bar due to swelling and pain in her left hand. Despite the resident's repeated attempts to inform the CNA of her inability to hold on, the CNA proceeded with the transfer alone, without the required safety belt and without a second staff member present. During the process, the resident lost her grip and fell to the floor. The facility's policy requires that mechanical lifts be operated by two trained staff members and that the safety belt always be used. Interviews with facility leadership confirmed that all CNAs are trained and must pass competency evaluations for lift use, but documentation of the CNA's training could not be located. The incident was not documented in the resident's nurse notes, but subsequent reports to the state health department confirmed the fall and the resident's resulting pain and medical evaluation.
Failure to Provide Prescribed Pain Medication Due to Medication Supply Lapse
Penalty
Summary
The facility failed to acquire, dispense, and administer a resident's prescribed pain medication as ordered by the physician. A resident with multiple medical conditions, including generalized weakness, polyarthralgia, lymphedema, obesity, gout, physical debility, osteoarthritis, hypertension, and diabetes, reported increased pain in her left hand and knees following a fall from a mechanical lift. The resident stated that her physician had prescribed Norco (Hydrocodone/Acetaminophen) to be taken every four hours as needed for pain, but she had not received this medication for about a week. Instead, she was only receiving Tylenol three times per day, which she reported was ineffective for her pain. Review of the resident's Medication Administration Record confirmed that she had not received Norco since 4/21/25, and the Controlled Drug Receipt/Record/Disposition Form showed that her supply of Norco had run out on that date. The nurse on duty confirmed that there had been no Norco available for three days and that the medication cart did not contain any of the prescribed pain medication. The failure to ensure timely ordering and availability of the resident's pain medication resulted in the resident not receiving her physician-ordered pain management.
Failure to Respect Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to respect the residents' right to dignity and respect, as evidenced by multiple incidents involving staff attitudes and behavior. Residents reported that call lights were not answered in a timely manner, with some waiting up to an hour or more. Certified Nursing Assistants (CNAs) were observed saying "not my resident" when asked to provide care, and residents expressed concerns about staff needing attitude adjustments. Specific incidents included a resident being left on the floor for an hour and a half after a fall, and another resident being brought to tears by a staff member's dismissive attitude regarding meal options. In one incident, a resident was upset and tearful after a CNA expressed frustration about additional work due to the night shift not completing their tasks. The resident felt scolded and disrespected by the CNA's tone of voice. Another resident reported that CNAs were loud and upsetting when waking them up early, causing distress. These incidents were reported to the Social Service Director and the Administrator, but the Administrator claimed to be unaware of the issues with staff attitudes and dignity/respect. The facility's Resident Council Minutes documented ongoing concerns with staff attitudes, including CNAs and nurses using phrases like "not my job" and "not my resident." Residents also reported that kitchen staff refused requests and that CNAs were often on their phones instead of attending to call lights. Despite these documented concerns, the Administrator stated that they had not been made aware of any specific issues with the staff involved, indicating a lack of communication and follow-up on reported grievances.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to follow up on grievances and document actions taken for six residents reviewed for grievances, potentially affecting all 51 residents in the facility. The facility's Resident Council Policy and Grievance policy require grievances to be documented and addressed, but the facility did not adhere to these policies. The Resident Council Minutes from September 2024 to February 2025 documented numerous concerns, including issues with meal service, laundry, housekeeping, and staff attitudes, but the facility's Grievance Log only documented follow-up actions for a few of these concerns. During a resident council meeting, several residents reported ongoing issues such as call light wait times, late medications, and missing personal items. These residents were unsure of the grievance reporting process and the facility's actions to address their concerns. Observations and interviews with staff confirmed that medications were not administered within the required time frame, and there was a lack of documentation for follow-up actions on grievances reported in the council meetings. The facility's staff, including the Activity Director and Social Services Director, acknowledged the repeated issues brought up in the resident council meetings. However, there was a lack of awareness and documentation regarding the follow-up actions taken for these concerns. The Social Services Director admitted to not having documentation for grievances from September 2024 to November 2024 and recognized the need to review resident council meeting minutes to ensure grievances are followed up on and documented.
Failure to Maintain Required Nursing Staff
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) and did not provide the services of a Registered Nurse (RN) for eight consecutive hours, seven days a week. This deficiency was observed over several days, specifically on 2/24/25, 2/27/25, 2/28/25, 3/1/25, and 3/2/25, where the facility lacked RN coverage for the required hours. Additionally, the facility has been without a full-time DON since 2/1/25, following the departure of the previous DON on 1/31/25. These findings were confirmed by the Assistant Director of Nursing and the Administrator, who acknowledged the absence of consistent RN coverage and a full-time DON, as documented in the facility's nursing working schedule and assessment.
Facility Lacks Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 51 residents. The Dietary Manager, who was actively supervising dietary operations, was hired a couple of weeks ago but does not currently hold a valid Food Safety/Dietary Manager Certificate, as it expired over a year ago. The Dietary Manager is scheduled to take the certification test next month, but at present, does not meet the State of Illinois standards to be a food service manager or dietary manager. The facility's assessment indicates the need for a full-time dietician or other clinically qualified nutrition professional to provide competent support and care for the resident population every day and during emergencies. The facility's application for Medicare and Medicaid documents that 51 residents reside in the facility.
Lack of Certified Dietary Staff in Food Service
Penalty
Summary
The facility failed to employ dietary support staff with the necessary competencies to effectively carry out the functions of the food and nutrition service, potentially affecting all 51 residents. Observations and interviews revealed that dietary aides were involved in preparing and distributing residents' meals without having the required training or food handler's certificates. Specifically, on two separate occasions, dietary aides were observed preparing food and assisting with meal distribution without proper certification. The Dietary Manager confirmed that four out of six kitchen staff members, including those observed, did not possess a Food Handler's certificate. The facility administrator acknowledged this deficiency, which is in violation of the Illinois Public Act requiring food handlers in non-restaurant settings, such as nursing homes, to have completed the necessary training since January 1, 2017.
Failure to Implement and Evaluate Performance Improvement Plan
Penalty
Summary
The facility failed to annually implement and evaluate the effectiveness of a performance improvement plan, which has the potential to affect all 51 residents. The facility's Quality Assurance Performance Improvement (QAPI) Plan requires an annual self-assessment and prioritization of activities, policies, and procedures, with continuous monitoring for improvement. However, the facility did not follow through with this requirement. The QAPI Plan includes input from staff, residents, and family members, as well as adverse events, performance indicators, survey findings, and complaints/grievances. Despite having a documented plan, there was no evidence of follow-up, monitoring, tracking, or evaluation of the interventions listed in the Performance Improvement Plans (PIPs) for preventative skin care and showers/baths. The administrator, who assumed the role in December 2024, acknowledged that the only PIPs available were from April, focusing on preventative skin care and showers/baths. These PIPs outlined specific goals and interventions, such as staff training, skin assessments, and hygiene schedules. However, there was no documentation of the implementation or evaluation of these interventions. The administrator was unable to locate any records of follow-up actions, attributing the lack of documentation to the former administrator's practice of discarding records. This oversight in maintaining and evaluating the PIPs indicates a significant deficiency in the facility's quality assurance processes.
Failure to Conduct Quarterly QA Meetings
Penalty
Summary
The facility failed to conduct quarterly Quality Assurance (QA) meetings, which is a requirement for maintaining compliance and ensuring the quality of care for all residents. The facility's Quality Assurance Performance Improvement (QAPI) Plan outlines the necessity of these meetings to proactively improve care, track and investigate adverse effects, and set quality targets. However, the facility only held one QA meeting in January 2025 since the current Administrator took over in December 2024. The Administrator acknowledged the absence of meetings in July and October 2024 and was unable to provide additional sign-in sheets for any other meetings in the past year. This oversight has the potential to impact all 51 residents in the facility, as documented in the facility's Long Term Care Facility Application for Medicare and Medicaid.
Failure to Implement Water Management and Infection Control Policies
Penalty
Summary
The facility failed to implement its water management plan, as evidenced by the Maintenance Director's admission of not having a test kit for water testing and not performing necessary checks on hot water distribution, eye wash stations, and hot water tanks. Additionally, there was no floor plan for Legionella management, and the Maintenance Director was unaware of where to obtain the necessary items for compliance. This lack of implementation poses a risk to all 51 residents in the facility. The facility also failed to adhere to its Pressure Wound Treatment Policy and Enhanced Barrier Precautions (EBP). An LPN improperly cleaned a resident's pressure wound by using the same side of a gauze pad repeatedly and brought the treatment cart into the resident's room, which is against protocol. Furthermore, there was a lack of EBP signage and PPE availability for residents with indwelling medical devices, such as urinary catheters. Staff members were not adequately trained on EBP, leading to improper use of protective equipment during care procedures, as seen in the cases of two residents with catheters.
Residents Unable to Access Personal Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents have access to their personal funds, as evidenced by the experiences of four residents. The facility's policy states that residents can access their funds during regular business hours, but withdrawals over $60 require a 24-hour notice. However, residents reported that they could not access their funds on weekends when the Business Office Manager, who manages the trust fund accounts, was not present. This issue was highlighted by a resident who stated they could not access their $60 monthly income on weekends, and during a resident council meeting, three other residents expressed similar concerns about not being able to obtain money from their accounts when the manager was absent. The facility's Trial Balance for resident trust fund accounts confirmed that the affected residents had personal fund accounts. The Business Office Manager acknowledged that they manage the accounts and only work one Saturday per month, while the Administrator, who also has access to the accounts, confirmed that no one is available on weekends to access these funds. This lack of access to personal funds on weekends and the absence of an alternative arrangement for fund access when the Business Office Manager is not present led to the deficiency.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for personal fund accounts for four residents, as required by their Resident Personal Trust Funds policy. The policy, dated 4/15/24, mandates that quarterly statements for all transactions be provided to residents or their legal representatives. However, interviews and record reviews revealed that residents did not receive these statements following a change of ownership on 11/1/24. Specifically, residents with personal fund accounts, including those with balances ranging from $381.00 to $5,199.75, did not receive the required quarterly statements. The Business Office Manager confirmed the oversight, acknowledging that the statements had not been distributed since the ownership change.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers for two residents, R9 and R43, who were dependent on staff assistance for their activities of daily living. R9, who has severe cognitive impairment and requires substantial assistance, did not receive any documented showers in February or March 2025, with only one refusal noted. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) confirmed the lack of documentation for R9's showers, bed baths, or refusals, despite the facility's policy of offering bed baths after three shower refusals and documenting all attempts. Similarly, R43, who is on hospice care and has multiple medical diagnoses including dementia and respiratory failure, did not receive the scheduled number of showers in December 2024, January 2025, and February 2025. The ADON reiterated the facility's policy of scheduling two showers per week and documenting all shower-related activities, but the records show that R43 received fewer showers than scheduled, with no documentation of refusals or bed baths. These deficiencies highlight a failure in the facility's adherence to its own policies for providing and documenting personal care for dependent residents.
Failure to Document and Administer Vaccinations
Penalty
Summary
The facility failed to provide immunization education, obtain immunization consent forms, and administer vaccinations for five residents reviewed for immunizations. These residents had no documentation in their medical records indicating that they were educated about vaccinations, consented to receive them, or were offered or administered the vaccines. On March 11, 2025, at 2:30 PM, the Corporate Nurse confirmed the absence of documentation for these residents. The facility's policy, revised on January 23, 2020, states that immunizations and vaccinations should be offered to prevent infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director.
Lack of Physician Order for Bedside Medication
Penalty
Summary
The facility failed to have a physician order for a medication found at the bedside for one resident reviewed for self-administration of medications. During an observation, a Combivent inhaler was found on the overbed table of a resident who stated they self-administer the inhaler two to four times per day and keep it in their room. However, the resident's March 2025 Physician Order Summary did not document an active order for the Combivent inhaler or for the resident to keep this medication at the bedside. A Registered Nurse confirmed the absence of an order for the inhaler after reviewing the resident's active physician orders and Medication Administration Record. The Assistant Director of Nursing stated that residents need an assessment and physician's order to keep medications at the bedside and self-administer.
Failure to Implement Physician-Ordered Treatments and Monitoring
Penalty
Summary
The facility failed to implement physician-ordered treatments and monitoring for a resident with lymphedema and congestive heart failure (CHF). The resident reported that their leg wraps, which were supposed to be applied every morning and removed every night, were not consistently managed, sometimes remaining on for several days. The resident's care plan listed diagnoses of lymphedema and CHF but lacked specific problems, goals, and interventions to address these conditions. Additionally, the physician's orders to monitor the resident's weight daily and notify the physician of significant weight gains were not consistently followed, with missing entries in the weight logs and no documentation of physician notification for weight gains. The resident's medical records showed significant weight fluctuations, including a 13-pound gain in one week and a 15-pound gain in five days, without evidence of physician notification. The facility's staff, including registered nurses and the Assistant Director of Nursing, acknowledged the lack of documentation and adherence to the physician's orders. The resident's lymphedema compression machine was also reported to be non-functional, and the facility had not documented the application of leg wraps in the Treatment Administration Record (TAR). The facility's failure to implement and document the necessary care and monitoring for the resident's conditions led to the identified deficiency.
Failure to Obtain Treatment Order and Monitor Pressure Ulcer
Penalty
Summary
The facility failed to obtain a treatment order for a newly discovered pressure area, monitor the area, and follow manufacturer's recommendations for treatment application for a resident with multiple diagnoses, including acute and chronic respiratory failure, type II diabetes mellitus, chronic obstructive pulmonary disease, and cognitive communication deficit. The resident's medical record did not list a pressure wound as a diagnosis, and there was a lack of documentation regarding the pressure area on the resident's buttocks. Hospice notes indicated redness on the buttocks, which later developed into a stage II wound, but the facility did not document or monitor this area in the Treatment Administration Records (TAR) for December 2024. A treatment order was not obtained until January 8, 2025, and the treatment did not commence until January 9, 2025. Additionally, there were no skin assessments for pressure wounds documented in the resident's medical record, and the care plan lacked documentation and interventions for pressure wounds. During an observation, a Licensed Practical Nurse (LPN) improperly applied a Calcium Alginate dressing by cutting it larger than the wound bed and covering unaffected skin, contrary to the manufacturer's instructions. The Assistant Director of Nursing (ADON) confirmed that the dressing should have been cut to fit the wound bed size. The facility's policy on the prevention of pressure wounds emphasized the need for timely and appropriate assessments, recognition, evaluation, reporting, and addressing changes in condition, which were not adhered to in this case.
Inadequate Catheter Care and Documentation for Residents
Penalty
Summary
The facility failed to provide adequate catheter care for two residents, leading to deficiencies in hygiene and documentation. One resident, who had a urinary catheter due to a history of bladder infections and urinary retention, reported that staff did not routinely clean the catheter or empty the drainage bag as requested. Observations confirmed that the resident's catheter tubing was dragging on the floor and the drainage bag was touching the floor, which was acknowledged by the CNAs as inappropriate. Additionally, the CNA did not clean the resident's labia/perineal area as required by the facility's catheter care policy. The resident's care plan and treatment administration record lacked documentation of catheter care and an active physician order for the catheter. Another resident with a suprapubic catheter received inadequate catheter care from a CNA who failed to use a new wipe for each cleaning stroke, reusing the same area of the wipe multiple times. This practice was acknowledged by the CNA as incorrect. The resident's medical record documented conditions such as Type 2 Diabetes Mellitus with Hyperglycemia and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, which necessitated the use of a catheter. These deficiencies highlight lapses in the facility's adherence to proper catheter care protocols and documentation requirements.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to administer medications according to physician orders and manufacturer recommendations for two residents, resulting in a medication error rate of 7.14 percent. For one resident, there was an order for Lisinopril 2.5 mg to be administered once a day, with instructions to hold the medication if the systolic blood pressure was less than 100. On the specified date, an LPN administered the medication without checking the resident's blood pressure at the time of administration, relying instead on a reading taken earlier during the night shift. The LPN admitted that there was no form to document blood pressures at the time of administration, which was confirmed by the Assistant Director of Nurses, who stated that blood pressure should be taken and recorded before administering the medication. For another resident, there was an order for Zofran disintegrating tablet 8 mg to be taken every six hours as needed for nausea and vomiting, with instructions for the tablet to be placed under the tongue to dissolve. However, the LPN placed the Zofran in a medication cup with other medications, and the resident swallowed it whole instead of allowing it to dissolve under the tongue. The LPN acknowledged that the resident usually picks the medication out of the cup to take last, but on this occasion, the resident swallowed it with the other medications. This deviation from the prescribed method of administration contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Follow Diet Order for Thickened Liquids
Penalty
Summary
The facility failed to adhere to a diet order for thickened liquids for one resident, identified as R210, who was part of a sample of 24 residents reviewed for meals. The deficiency was observed when R210's breakfast and noon meal trays contained regular consistency liquids instead of the prescribed thickened liquids. Certified Nursing Assistants (CNAs) confirmed that R210's meal trays did not document the need for thickened liquids, despite the resident's known requirement for them due to coughing and congestion. The facility's Diet Orders policy requires that diet orders be communicated in writing to the dietary department, but this was not followed in R210's case. The March 2025 Physician Order Summary for R210 did not list thickened liquids, and the resident's meal tray card lacked documentation for the required diet modification. A Diet Order Form dated February 22, 2025, indicated that R210 should receive nectar thickened liquids, but this was not reflected in the meals provided. The Assistant Director of Nursing and a Registered Nurse acknowledged the oversight, noting that the diet order from the hospice nurse was not updated in the resident's Physician Order Summary, leading to the failure in providing the correct diet consistency.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day, as required, on two specific dates, 8/4/24 and 8/7/24. This deficiency was identified through interviews and record reviews, which revealed that the facility's August 2024 Nurse Schedule and Nursing Daily Sheets did not document an RN being scheduled to work on those days. During a review of staffing and daily sheets with the Director of Nursing (V2), it was confirmed that there was no RN on duty on the specified dates. The Director of Nursing explained that the absence of RN coverage was due to both V2 and another RN (V3) being out sick with COVID-19. The facility had 46 residents at the time of the deficiency, all of whom were potentially affected by the lack of RN coverage.
Inadequate Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide adequate dietary staff to ensure meals were served on time, affecting four out of five residents reviewed for meals in a sample of 13, with the potential to impact all 46 residents. Interviews and record reviews revealed that during a COVID-19 outbreak, kitchen staff shortages led to significant delays in meal service. Residents reported breakfast being served as late as 11:00 AM instead of the scheduled 8:00 AM, with lunch and supper also delayed by several hours. The facility's dietary manager, who had been employed for only three weeks, acknowledged the staffing issues and noted that meals were considered timely if served within 25 minutes of the scheduled time. Staff members, including a Licensed Practical Nurse and the Social Services Director, confirmed the delays and the need for additional staff to assist in the kitchen. The facility's dietary schedule showed that between August 4th and August 11th, there were multiple days with only one kitchen staff member available, and the dietary manager had to step in as the second staff member. The facility's assessment indicated a staffing plan that included one food and nutrition supervisor, one cook, and one dietary aide for weekdays, with reduced staffing on weekends. Despite these plans, the facility struggled to maintain timely meal service during the staffing shortages.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which has the potential to affect all 46 residents residing in the facility. During a kitchen tour with the Dietary Manager, dust and debris were observed on the floor, and dirt had built up around the range and prep table. Additionally, there were dark, dried splatters on the side of the range and on the wall near the three-sink washing station. The Dietary Aide confirmed that the floors are supposed to be swept and mopped at the end of each shift, which should have been done the previous evening. Despite the facility's Cleaning Schedule requiring a cleaning rotation form for proper sanitation, the Dietary Manager did not have a cleaning log or schedule in place.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement effective infection control measures during a COVID-19 outbreak, affecting all 46 residents. The outbreak began on August 1, 2024, and by August 8, 2024, 24 residents and 16 employees had tested positive for COVID-19. The facility did not maintain an adequate supply of N95 respirators, and staff were observed wearing KN90 and KN95 masks instead, which were not changed between COVID-19 positive and negative rooms. Staff, including CNAs and housekeepers, were not consistently wearing appropriate PPE, such as gowns and gloves, when entering COVID-19 positive rooms, and masks were often worn incorrectly with the lower strap hanging loose. The facility's Director of Nursing (DON) admitted that the facility had a limited supply of N95 masks and had not been routinely ordering them due to the absence of previous outbreaks. When the outbreak began, the facility quickly ran out of N95 masks and relied on KN95 and KN90 masks provided by the local health department. Staff were not adequately trained on the proper use of PPE, as evidenced by multiple staff members wearing masks incorrectly and not changing or disinfecting masks and eye protection between rooms. The facility's policy required N95 masks and eye protection during resident care in outbreak situations, but this was not adhered to. Housekeeping practices were also insufficient, with high-touch surfaces being disinfected only every other day instead of the recommended three times per day. The facility was understaffed in housekeeping, with laundry staff having to cover housekeeping duties, leading to uncertainty about whether resident rooms were cleaned daily. The facility's COVID-19 Control Measures policy required increased cleaning frequency during outbreaks, but this was not consistently implemented, contributing to the spread of the virus within the facility.
Non-Functioning Call Lights Lead to Delayed Resident Assistance
Penalty
Summary
The facility failed to maintain functioning call lights for four residents, leading to significant delays in staff response to resident needs. Observations revealed that residents were using handheld bells as a substitute for non-functioning call lights. One resident reported waiting over 30 minutes for assistance, while another resident had to wait an hour while lying in urine and feces. Staff interviews confirmed that the call lights had been non-functional for weeks, affecting both the North and South Halls of the facility. The residents affected by this deficiency included individuals with varying levels of cognitive impairment and incontinence, all of whom required substantial assistance for toileting. The facility's administrator acknowledged the issue, stating that the call lights had been problematic since February 2024 and that budget constraints had prevented necessary repairs or replacement of the system. Despite evaluations by corporate and sister facility maintenance staff, the call light system remained in disrepair, necessitating the use of handheld bells for resident communication.
Insufficient Housekeeping Staff Leads to Unclean Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment due to insufficient housekeeping staff, affecting three residents. On the specified date, a resident reported that their room was not cleaned daily, with observations of a sticky floor, overflowing garbage, and a bathroom with dried feces. This resident was documented as cognitively intact. Another resident also reported that their room had not been cleaned, with dust and food wrappers present, and mentioned that housekeeping staff were out sick with COVID-19, leading to rooms not being cleaned daily. This resident was also documented as cognitively intact. A third resident expressed concerns about the cleanliness of their room, noting that the facility lacked sufficient housekeeping staff. This resident had a moderate cognitive impairment. The facility's housekeeping schedule showed no housekeeping staff were scheduled for several days, and the Housekeeping Supervisor confirmed that the facility had not been fully staffed for some time. The supervisor also noted that laundry staff had to cover housekeeping duties when staff were out sick, which may have impacted the daily cleaning of resident rooms. The facility's policy required daily cleaning tasks, including sweeping, mopping, and bathroom cleaning.
Failure to Provide Scheduled Showers During COVID-19 Outbreak
Penalty
Summary
The facility failed to provide scheduled showers for a resident who is dependent on staff for bathing. The resident, who is cognitively intact, reported not receiving a shower for two weeks, despite preferring weekly showers. This lapse occurred during a COVID-19 outbreak at the facility, which led to a staffing shortage. The resident's showers were scheduled for Thursdays, but the last recorded shower was on the first of the month. A Registered Nurse confirmed the staffing shortage due to the outbreak, and a Certified Nursing Assistant, responsible for showers, verified that the resident did not receive a shower on the scheduled day due to the outbreak.
Failure to Follow Physician-Ordered Diet for Diabetic Resident
Penalty
Summary
The facility failed to adhere to a physician-ordered diet for a resident diagnosed with Type 2 Diabetes Mellitus. The resident, who is cognitively intact, reported not being on a special diet despite having a physician's order for a Controlled Carbohydrate diet. During meal service, the resident was served a regular diet meal that included Salisbury steak, mashed potatoes, bread, and ice cream, which did not align with the prescribed Controlled Carbohydrate diet. The Dietary Manager confirmed that the resident's meal tray card incorrectly documented a regular diet instead of the prescribed Controlled Carbohydrate diet. The discrepancy was attributed to an oversight on the Diet Order Form, where the box for the Controlled Carbohydrate diet was not marked. The facility's menu and dietary guidelines specify modifications for Controlled Carbohydrate diets, such as substituting fruit for dessert and omitting extra bread, which were not followed in this instance.
Lack of Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition, which has the potential to affect all 49 residents residing in the facility. The facility's assessment indicated that a dietician or other clinically qualified nutrition professional should serve as the director of food and nutrition services. However, the dietary schedule showed no dietary manager until July 25, 2024, and no certified dietary manager was on staff during the month of July 2024. The Administrator admitted to cooking for the last 12-14 days due to a lack of staff, including a dietary manager. Although a dietary manager was hired and started orientation on July 25, 2024, the Administrator could not provide documentation that the new hire was a certified dietary manager or had other credentials to support her knowledge of the role.
Inadequate Staffing in Dietary Department Leads to Meal Delays
Penalty
Summary
The facility failed to provide sufficient and competent staffing in the food and nutrition services department, affecting the timely delivery of meals to residents. The facility's policy requires adequate staffing to meet the dietary needs of residents, but the facility assessment indicated a need for more hours from both a director and staff in food and nutrition services. The administrator reported having to cook for the past 12-14 days due to a lack of staff, including a dietary manager. The dietary schedule showed multiple instances where no cook was scheduled for various meals, leading to delays in meal service. On one occasion, the Director of Nursing was observed cooking breakfast because dietary aides were not trained to cook. Residents expressed dissatisfaction with the delays, with one resident stating they were very hungry and another not receiving breakfast until much later than scheduled. The administrator confirmed that the lack of dietary staff was causing meals to be served late, and the dietary manager had been overworked, leading to an absence. Additionally, an incident was reported where a staff member snapped at a resident due to stress from working alone in the kitchen.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect two residents from verbal and mental abuse, as evidenced by an incident involving a cook, identified as V4, and a resident, R1, who is severely cognitively impaired. On the night of the incident, the dietary department was short-staffed, and V4 was observed yelling at R1, threatening to stop serving dinner if R1 did not comply with his demands. V4 also threatened to make R1 eat last. A Certified Nursing Assistant (CNA), V5, witnessed V4 raise his hand as if to hit R1, but intervened by moving R1 away to prevent physical contact. This incident was corroborated by another resident, R2, who is cognitively intact and reported the event to the Resident Care Coordinator. The facility's Abuse Prevention Program Policy, dated 11/28/2016, affirms residents' rights to be free from abuse, including verbal abuse from staff. Despite this policy, the incident occurred, indicating a failure to adhere to the established guidelines. The administrator, V1, was informed of the incident and acknowledged that V4 had threatened R1 and subsequently terminated V4 for his behavior. However, the report focuses on the deficiency in protecting residents from abuse, as demonstrated by the actions of V4 and the facility's inability to prevent such an incident from occurring.
Failure to Report and Remove Alleged Abuser
Penalty
Summary
The facility failed to implement its abuse prevention policy by not immediately reporting suspected abuse and not ensuring the alleged abuser was removed from the facility. An incident occurred between a resident (R1) and a cook (V4) during the evening meal, where the cook allegedly threatened the resident and raised a hand to hit him. This incident was witnessed by a Certified Nursing Assistant (V5), who intervened to prevent physical contact. Despite witnessing the incident, the CNA did not report it immediately, and the cook was allowed to leave the facility without being removed from resident contact as per the facility's policy. The Resident Care Coordinator (V3) was informed of the incident by another resident (R2) and the CNA later that evening. The RCC then reported the incident to the Director of Nursing (V2) and the Administrator (V1) via text message. By the time the Administrator arrived at the facility, the cook had already left. The facility's failure to immediately report the incident and remove the alleged abuser from resident contact constitutes a breach of their abuse prevention policy.
Lack of Qualified Director of Food and Nutrition
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition, which has the potential to affect all 47 residents residing in the facility. During the survey conducted from 7/18/24 to 7/19/24, it was observed that the facility did not have a Dietary Manager present. The Administrator, identified as V1, stated that the facility had a Dietary Manager for only five days before the individual abandoned the job, leading to their termination. As a result, V1 and the Director of Nursing (DON), identified as V2, have been taking on cooking responsibilities. V1 mentioned working in the kitchen frequently, including weekends, while V2 confirmed having cooked for the past one and a half to two weeks. The facility's Food Service Manager job summary requires the individual to have taken or be willing to take the Dietary Managers Course and pass the sanitation test or be willing to take a state-approved course. The facility assessment indicates the need for a Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services for 8 hours per day.
Lack of Qualified Dietary Staff
Penalty
Summary
The facility failed to provide qualified dietary aides and a cook, which has the potential to affect all 47 residents residing in the facility. The facility's assessment indicated that food and nutrition services staff should be present for 14 hours per day. However, the dietary aides and cook lacked the necessary certifications. The Diet Aide job summary required aides to pass a sanitation test or be willing to take a state-approved course and receive food handler's training within 30 days of employment. On multiple occasions, it was confirmed through interviews with the Director of Nursing (DON) and the Administrator that the cook and dietary aides did not possess the required cooking/sanitation and food handler's certificates. The cook, who had been working for one and a half to two weeks, was unaware of the certification requirement until informed during the survey.
Failure to Administer Dietary Supplement as Ordered
Penalty
Summary
The facility failed to administer a dietary supplement according to physician's orders for a resident diagnosed with Transischemic Attack (TIA) and Cerebral Infarction. The resident's Physician Order Sheet specified that Med Pass 2.0 Supplement, 60 milliliters by mouth twice a day, was to be administered from July 1 to July 31, 2024. However, the Medication Administration Record indicated that the supplement was not given on several occasions: both AM and PM on July 7 and July 11, PM on July 16, and AM on July 19. The Director of Nursing confirmed that the supplement was not administered on these dates. The resident's care plan, dated March 22, 2024, required that supplements be provided and served as ordered. The facility's policy on conformance with physician medication orders, last reviewed in September 2017, mandates that all medications and supplements be given upon written order of a physician.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and mental abuse by a staff member. The incident involved a Certified Nurses Assistant (CNA) who was verbally inappropriate towards a resident diagnosed with Congestive Heart Failure, Depression, Bipolar Disorder, Post Traumatic Stress Disorder, and Neuropathy. The resident, who is cognitively intact, reported that the CNA raised her voice, yelled, and cursed at her when she requested hot chocolate. The CNA's behavior made the resident feel embarrassed, humiliated, and like a burden. The resident reported the incident to the Assistant Director of Nurses and later encountered the CNA again, who snapped at her for getting her in trouble. The facility's Abuse Prevention Program affirms the right of residents to be free from abuse, including verbal and mental abuse. The Abuse Investigation Report confirmed that the CNA engaged in inappropriate and unprofessional behavior directed towards the resident. The CNA was terminated after the conclusion of the investigation. The facility's administrator confirmed that the incident occurred as reported by the resident.
Insufficient RN Coverage
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on four of eighteen days reviewed for RN staffing, potentially affecting all 49 residents. The facility's nursing schedules from April 23, 2024, through May 10, 2024, revealed that on April 23, 25, and 27, only four hours of RN coverage were scheduled for each 24-hour period, and on April 29, no RN coverage was scheduled at all. This deficiency was confirmed by the Resident Care Coordinator on May 9, 2024, who verified the accuracy of the nursing schedule and acknowledged the insufficient RN coverage on the specified dates. The Long-Term Care Facility Application for Medicare and Medicaid report dated May 8, 2024, documented that 49 residents resided in the facility during this period.
Unsanitary Range Hood and Inadequate Dishwasher Sanitization
Penalty
Summary
The facility failed to maintain the range hood in a sanitary condition and did not ensure the commercial dishwasher's sanitizer levels were adequate. During an observation, the range hood was found to have a dull appearance with a light brown greasy substance and darker brown grease trails. Food items, including Brussels sprouts and blueberry cobbler, were being prepared directly underneath the unsanitary hood. The last documented cleaning date for the range hood was nearly a year prior, and the Dietary Manager acknowledged the need for professional cleaning services. Additionally, the commercial dishwasher was found to have insufficient chlorine levels for proper sanitization. The Dietary Manager tested the dishwasher's sanitation cycle, which showed chlorine levels of 10 parts per million (ppm) or less, far below the required 50-100 ppm. Despite attempts to fix the issue by adjusting the tubing, the chlorine levels remained inadequate. The Dietary Aide continued to use the dishwasher without further instruction, potentially compromising the cleanliness of the dishware and utensils used by the facility's 49 residents.
Failure to Conduct Quarterly QA Meetings
Penalty
Summary
The facility failed to conduct quarterly Quality Assurance (QA) meetings as required. The only documented QA meeting in the past year was held on 4/26/2024, which covered the months of January, February, and March 2024. There were no other documented QA meeting sign-in sheets for any other quarters. This was confirmed by the Administrator and Regional Support, who acknowledged the absence of additional sign-in sheets. The facility's undated Quality Assurance Plan policy states that quarterly meetings are mandatory. At the time of the survey, the facility had 49 residents, as documented in the Resident Roster and Form 671, Long Term Care Facility Application for Medicare and Medicaid.
Delayed Call Light Responses and Lack of Privacy During Insulin Administration
Penalty
Summary
The facility failed to answer call lights in a timely manner for seven residents and did not provide privacy while administering an insulin injection to one resident. Resident Council Meeting Minutes consistently documented complaints about delayed responses to call lights over several months. During a resident council interview, multiple residents confirmed that call lights were not answered promptly on each shift. Additionally, an LPN administered insulin to a resident in the dining room in the presence of other residents, stating that this was the usual practice and that no one had instructed otherwise. The facility's Residents' Rights pamphlet emphasizes the right to privacy and timely services, which were not upheld in these instances.
Failure to Label Insulin Pens After Opening
Penalty
Summary
The facility failed to label insulin pens after opening for five residents (R5, R15, R16, R27, R40) as required by their policy. The Physician Order Sheets (POS) for these residents documented various insulin prescriptions, including Insulin Glargine, Fiasp, Insulin Lispro, Novolog, and Levemir, to be administered multiple times daily. However, during an observation on 5/8/24, it was noted that the insulin pens for these residents did not have open dates documented. V17, an LPN, incorrectly identified the delivery received dates as the date of opening, which was contrary to the facility's policy that mandates dating the insulin pens when they are opened. Further, V5, another LPN and Resident Care Coordinator, confirmed that the insulin pens should indeed be dated when opened, aligning with the facility's Procurement and Storage of Medications Policy dated 11/6/18. This policy clearly states that all medication containers must be labeled with the date opened by the person breaking the seal. The failure to follow this policy was observed during the survey, leading to the identification of this deficiency.
Failure to Ensure Palatable and Attractive Food
Penalty
Summary
The facility failed to ensure that food served was palatable and attractive, affecting seven residents. During a resident council interview, multiple residents reported that the food was terrible, unappetizing, and often served at incorrect temperatures. Resident Council Minutes documented ongoing complaints about food quality, including issues with cold food, lack of variety, and specific requests for different food items. On a specific date, the surveyor and the administrator observed uneaten lunch plates with hard and cold carrots, which residents stated were inedible and could potentially break their teeth.
Failure to Provide Advance Beneficiary Notice
Penalty
Summary
The facility failed to provide a resident with an Advance Beneficiary Notice (ABN) at the termination of a Medicare Part A covered stay. This failure nullified the resident's right to continue therapy services at their own expense or decline therapy services. The deficiency affected one resident out of a sample of three reviewed for Beneficiary Notices. The resident began a Medicare Part A covered stay on 3/26/24, with the last covered date being 4/4/24. There was no evidence that the resident received an ABN outlining their options. The Business Office Manager acknowledged the oversight and was unable to explain why the ABN was not issued for this resident, despite having issued ABNs for other residents discharged from Medicare Part A.
Failure to Report and Investigate Incidents
Penalty
Summary
The facility failed to report and notify the Administrator and a supervisor of injuries of unknown origin and failed to notify the administrator of a resident-to-resident incident for three residents. Resident 11 (R11) had multiple diagnoses including Acute Metabolic Encephalopathy, History of falling, and Anxiety. On 5/2/24, R11 was found with bruises on both hands and upper stomach, but there was no documentation of an investigation into these injuries. Similarly, Resident 17 (R17) and Resident 31 (R31) were involved in an incident where R31 upset R17 by changing the television settings, but this incident was also not reported or investigated. The Administrator (V1) was unaware of both incidents and stated that staff should have reported these incidents for investigation. The facility's Abuse Prevention Program Policy, dated 2/2019, mandates that employees are to immediately report any occurrences of potential or alleged abuse to a supervisor and the administrator. However, in these cases, the staff failed to follow this policy, resulting in a lack of investigation and documentation for the incidents involving R11, R17, and R31. This failure to report and investigate potential abuse or resident-to-resident incidents constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Complete MDS Assessments in Required Time Frames
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frames for two residents. Resident R14 was admitted on 12/21/23, and the MDS assessment reference date was set for 12/28/23. However, the Care Area Assessments and Care Plan Completion were not signed as completed until 3/27/24, which is well beyond the required 14-day period for MDS completion and the additional 7 days for Care Plan Completion. Similarly, Resident R39 was admitted on 12/20/23, with an MDS assessment reference date of 12/27/23. The Care Area Assessments and Care Plan Completion for R39 were also not signed until 3/27/24, exceeding the mandated time frames. The Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual specifies that the comprehensive Admission MDS and Care Area Assessments must be completed no later than the fourteenth day from admission, and the Care Plan must be completed within 7 days after the MDS completion. The facility's Minimum Data Set reimbursement Specialist confirmed that the assessments were not completed within the required time frames, indicating a systemic issue in adhering to the mandated assessment schedule.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to encode and transmit residents' Minimum Data Set (MDS) Assessments within the required time frame, affecting two residents out of a sample of 32. Specifically, Resident 14's Admission MDS had an Assessment Reference Date of 12/28/23, but the completion date was documented as 3/27/24. Similarly, Resident 39's Admission MDS had an Assessment Reference Date of 12/27/23, with the completion date also documented as 3/27/24. According to the Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual, the timetable for transmitting a completed MDS is no later than twenty-one days after the completion date. The Minimum Data Set reimbursement Specialist confirmed that the facility sets the Assessment Reference Date for 14 days after admission, completes the MDS the next day, and then has another 14 days to transmit the MDS.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to encode residents' Minimum Data Sets (MDS) accurately, affecting two residents out of ten reviewed. For one resident, the MDS inaccurately documented the presence of a stage 3 pressure ulcer, which was not supported by any medical records or staff statements. The resident had venous ulcers that resolved months prior, and there was no evidence of any pressure ulcer treatments in the medical records. Both the Licensed Practical Nurse and the Resident Care Coordinator confirmed that the resident never had a pressure ulcer since admission. For another resident, the MDS incorrectly indicated the presence of a feeding tube, which was not corroborated by any medical records or staff interviews. The resident's comprehensive physical assessments and clinical histories did not document any feeding tube, and staff members recalled the resident having a urinary catheter but no feeding tube. The Resident Care Coordinator confirmed that the resident never had a gastrostomy tube since admission.
Failure to Obtain Level 2 PASARR for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to obtain a Level 2 Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with severe mental illness (SMI) while residing in the facility. This deficiency was identified during an interview and record review, which revealed that the resident's Level 1 PASARR dated 10/6/22 indicated that a Level 2 screen was not required because the resident was not diagnosed with any SMI, intellectual disability (ID), or related condition (RC). However, the resident's cumulative diagnosis log and current physician order sheet documented diagnoses of schizophrenia and psychosis, both severe mental illnesses. The resident was admitted to the facility on 10/7/22. The Business Office Manager suggested that the hospital might not have included the mental illness diagnosis in the system before the resident's transfer to 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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