Integrity Hc Of Carbondale
Inspection history, citations, penalties and survey trends for this long-term care facility in Carbondale, Illinois.
- Location
- 120 North Tower Road, Carbondale, Illinois 62901
- CMS Provider Number
- 145757
- Inspections on file
- 34
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Integrity Hc Of Carbondale during CMS and state inspections, most recent first.
The facility did not develop individualized discharge plans or adequately involve residents, their representatives, and the interdisciplinary team in transfer decisions for multiple residents during a period of facility repairs. Several residents and families received very short notice, were not given written notifications, and had limited or no discussion of transfer options, resulting in emotional distress and confusion for some residents.
A resident with a history of dementia, weakness, and high fall risk sustained multiple contusions and skin tears after falling from a bed that was left in a high position without a fall mat in place, contrary to the care plan and facility policy. Staff interviews confirmed the required fall prevention interventions were not implemented at the time of the incident.
The facility did not provide timely written notification of transfer, reasons for transfer, or appeal rights to multiple residents and their representatives during a temporary closure for repairs. Instead, residents and families were often informed verbally with very short notice, and the Ombudsman was not formally notified. Documentation lacked evidence of required written notices or discharge planning, and residents reported inconvenience and lack of choice regarding their transfers.
A resident with dementia and cognitive deficits was placed in a room with a nonfunctioning, padlocked bathroom, leading to confusion and multiple episodes of incontinence in inappropriate places. Staff provided a bedside commode, but the resident continued to have difficulty due to poor eyesight and confusion, and was not moved to a room with a working bathroom until much later. After relocation, the resident was able to use the bathroom independently without further incidents.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall, resulting in pain and inability to bear weight. Despite these symptoms, an LPN did not order stat imaging or notify the physician when imaging could not be performed the same day. The resident remained in pain and without appropriate diagnostic evaluation for over 24 hours until imaging revealed a hip fracture, after which the resident was transferred to the hospital.
A resident with multiple health conditions suffered a fall and reported significant pain, but did not receive pain medication for several hours despite staff being notified multiple times. The resident was later found to have a displaced femoral neck fracture, and records showed that pain management was delayed until the following day, contrary to physician orders and facility policy.
Several residents with cognitive and physical impairments were provided with positioning devices and bed or chair alarms without proper restraint assessments or physician orders. Staff and therapy personnel indicated that such devices were not routinely evaluated or considered restraints, and the facility lacked a policy on physical restraints. Residents were unable to demonstrate independent removal of some devices, and documentation was incomplete or missing.
A resident with severe dementia and neuropsychiatric diagnoses was frequently administered as-needed psychotropic medications without consistent attempts at person-centered behavioral interventions or documentation of less restrictive alternatives. Staff were unclear on specific behavioral strategies, care plan records were incomplete, and there was no facility policy guiding psychotropic medication use or monitoring for side effects.
The facility did not ensure that an RN was present for 8 consecutive hours each day on multiple occasions, as confirmed by schedule reviews and staff interviews. This deficiency affected all 50 residents in the facility.
Surveyors found unsanitary conditions in the kitchen, including food debris, black dirt, dead cockroaches, and grease buildup on floors and equipment. The Dietary Manager reported ongoing issues with staff not maintaining cleanliness, and the RD expected sanitary conditions. Fifty residents were present during the time of these observations.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in residents' nutritional needs not being met according to their individual requirements.
Multiple residents with chronic conditions reported receiving cold, unappetizing, or undercooked meals, including cold pizza, burned hamburgers, and raw scalloped potatoes. Direct observation and food temperature checks confirmed that food was served below recommended temperatures and was not palatable, with no substitutions offered when meals were refused.
Three residents with cognitive impairment and at risk for weight loss did not receive prescribed dietary supplements or appropriate meal modifications as ordered. Observations showed that required health shakes, extra butter/margarine, sauces, and pudding were not provided, and meal textures were not properly prepared, contrary to physician and dietitian orders.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors.
The facility did not provide enough dietary staff to serve dinner on time, resulting in significant meal delays for all residents. On the evening in question, only one dietary aide was present, with CNAs and some residents assisting in meal preparation and tray clearing. Multiple residents reported receiving their meals late, and observations confirmed that dinner service began much later than scheduled.
After the kitchen was closed by the health department due to pests and sanitation issues, staff prepared and served meals by grilling food outside and staging trays in a room without proper handwashing or dishwashing facilities. Food was handled without consistent hand hygiene, and the dish machine sanitizer was below required levels, affecting all residents.
A black, mold-like substance was observed covering about half of an air vent and surrounding ceiling tiles in a hallway near the dining area and meal tray staging room, affecting 14 residents. The DON acknowledged the issue and reported it to the administrator, but the area remained uncleaned during multiple observations, contrary to facility policy requiring regular cleaning and disinfection.
Several residents requiring pureed and mechanical soft diets were served food that was dry, crusty, grayish, or burnt after being microwaved, with staff and residents reporting the meals were unappetizing and insufficient. Staff acknowledged the food's poor appearance and cited inadequate planning and equipment as contributing factors.
A resident with dementia and a traumatic brain injury repeatedly eloped from the facility without staff knowledge, including an incident where the resident walked 0.8 miles away. Despite multiple elopements, the facility failed to investigate or implement new interventions, resulting in an Immediate Jeopardy situation. The resident's care plan was not updated, and staff interviews revealed inconsistent supervision and inaudible alarms.
A resident with diabetes missed three doses of long-acting insulin due to the facility's failure to follow physician's orders and notify the physician of elevated blood sugar levels. The resident's family reported issues with medication administration, and the facility's process for handling new admissions was not effectively implemented, leading to significant medication errors.
The facility failed to serve food at appetizing temperatures, affecting several residents. Interviews and observations revealed that meals, especially breakfast, were often cold when delivered to residents' rooms. The dietary cart used was not insulated, causing food to sit for over 30 minutes and lose heat. The Dietary Director acknowledged the delay in delivery as a contributing factor.
The facility failed to maintain sanitary food and ice handling practices. A container of sugar was left accessible to residents, who used a shared portion cup to scoop sugar, potentially contaminating it. Additionally, residents and staff were observed using ice scoops improperly, touching unclean surfaces before placing the scoops back into the ice coolers. These practices were confirmed by residents and acknowledged by the Dietary Director.
The facility failed to implement proper infection control practices for Enhanced Barrier Precautions and COVID-19. Staff did not adhere to guidelines for gown use during direct care for residents with medical devices and wounds. Additionally, residents with COVID-19 were not properly isolated from those who tested negative, contrary to CDC guidelines.
A facility failed to maintain a resident's dignity during dining assistance when a CNA stood while feeding a resident with severe cognitive impairment. The resident, with diagnoses including dementia and Parkinson's disease, consumed only 25% of the meal. Interviews revealed that CNAs are expected to sit and make eye contact during feeding, but no formal policy on eating assistance or dignity was available.
The facility failed to accommodate the preferences of two residents regarding room conditions and showering, impacting their dignity. One resident with dementia was often found sitting in a dark room without the TV on, despite family concerns. Another resident, requiring assistance for showering, reported not receiving regular showers as scheduled. The facility lacked a formal shower policy, contributing to inconsistent care.
A resident with diabetes was admitted to the facility and did not receive prescribed insulin due to pharmacy delivery issues. Despite elevated blood sugar levels, the physician was not informed until several days later. Family members reported difficulties in obtaining medications, and staff acknowledged the physician should have been contacted about the missed doses and high blood sugar levels.
A resident with moderate cognitive impairment and dependent on assistance for personal care was exposed during wound and urinary catheter treatments. Staff failed to draw curtains or blinds, compromising the resident's privacy. The resident expressed distress over the lack of privacy, feeling dehumanized by the staff's actions.
A resident with vascular dementia and type 2 diabetes was reportedly verbally abused by a nurse on the first day of admission. Family members witnessed the nurse using inappropriate language, but the facility's investigation could not substantiate the allegations due to a lack of evidence. The incident was deemed a misunderstanding due to cultural differences, and the resident showed no signs of distress.
A facility failed to substantiate and address an allegation of verbal and mental abuse involving a resident with dementia. Family members reported a nurse yelling and using inappropriate language, but the facility's investigation found no corroborating evidence. The nurse returned to work, and the incident was deemed a misunderstanding due to cultural differences, despite the facility's abuse prevention policy.
A facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with a fracture of the femur, falls, epilepsy, and muscle weakness. The resident's medical record lacked documentation of a baseline care plan. The DON stated that the responsible nurse had forgotten to complete it, and it was being addressed at the time of the interview.
A resident with multiple medical conditions, including a stage 4 pressure ulcer and severe cognitive impairment, did not receive proper catheter care as per facility policy. An LPN cleaned the resident's groin and catheter area with soapy water but failed to rinse and dry the area, which is a necessary step to prevent infections.
A resident with a gastrostomy tube did not have the tube placement checked before medication and feeding administration, contrary to facility policy. The resident, with severe cognitive impairment and dependent on eating, was observed receiving medications and feedings without proper placement verification. Interviews with staff confirmed the facility's procedure requires aspirating stomach contents to check placement, which was not done.
A resident in a LTC facility experienced neglect when staff failed to assess and treat pressure ulcers, continued psychotropic medications without orders, and neglected oral care. The resident, who was at risk for skin breakdown, developed multiple new wounds and was hospitalized for altered mental status and possible sepsis. Communication failures and inadequate adherence to care policies contributed to the neglect.
The facility failed to provide adequate oral care for two residents, leading to significant oral health issues. One resident had a severe buildup on the tongue due to lack of care, while another reported that her teeth were not brushed and oral care items were not provided. Staff interviews confirmed that oral care was not routinely offered, and care plans lacked specific interventions for oral hygiene.
A facility failed to prevent and treat pressure ulcers for several residents, leading to significant skin breakdowns. One resident developed multiple pressure ulcers, including Stage 2 and Stage 3 ulcers, due to inadequate assessments and interventions. Another resident had new open areas and mushy heels that were not documented or treated. A third resident had a wound on the elbow that was not properly documented or treated, despite having a care plan for prevention. The facility's policy on pressure area care was not followed, contributing to the development and worsening of pressure ulcers.
The facility failed to administer medications per standards of practice, with an LPN handling medications without proper hygiene and leaving a medication cart unlocked. A resident self-administered medications without supervision or a documented assessment, and another was left with medications unsupervised. The DON noted the absence of necessary orders and assessments.
A resident was administered unnecessary psychotropic medications after returning from a hospital stay where the medications were discontinued. Despite hospital instructions, the facility continued to give Clonazepam and Haldol due to miscommunication and assumptions among staff, leading to the resident receiving these medications unnecessarily.
A resident with a gastrostomy tube did not receive tube feeding as ordered due to communication and documentation issues. The facility continued bolus feedings despite a recommendation for continuous feeding, as the order was not signed by the PCP and compatible tubing was unavailable. Staff were unaware of the feeding discrepancies, and the facility lacked a system to track diet change recommendations.
The facility failed to document and reconcile narcotic medications accurately for several residents, leading to potential medication diversion. An LPN was the sole nurse administering narcotics without proper documentation, and the DON suspected diversion but did not investigate. The facility's policies on narcotic diversion and documentation were not followed, resulting in unaccounted medications and potential risks to resident safety.
The facility failed to prevent the misappropriation of resident property and controlled medications for six residents. An LPN was the only nurse administering narcotics, with discrepancies in medication records and missing medications. Residents reported suspicions of not receiving pain medications, and a missing laptop was not thoroughly investigated. The facility did not follow its policies on abuse prevention and controlled substance management, leading to potential medication diversion.
The facility failed to report allegations of abuse and misappropriation of property within required time frames. A resident's missing laptop was not investigated until surveyors intervened. Another resident's verbal abuse allegation was dismissed by the DON, and no investigation was initiated. Additionally, an incident involving the DON raising her voice in front of a resident was not reported as abuse. A resident suspected a nurse of not administering pain medication, but no investigation was conducted.
The facility failed to investigate abuse allegations in a timely manner for several residents. A resident's missing laptop was not promptly investigated, and verbal abuse allegations by a CNA were initially dismissed. Additionally, an incident involving the DON yelling at therapists in front of a resident was not investigated, and a resident's suspicion of a nurse not administering pain medication was not addressed. These deficiencies highlight the facility's inadequate response to abuse allegations.
The facility failed to provide timely and dignified care for two residents, leading to prolonged wait times for assistance and an incontinent episode. Both residents reported waiting up to 45 minutes for help, despite their care plans and facility procedures emphasizing prompt response to call lights.
Failure to Provide Individualized Discharge Planning During Facility Transfers
Penalty
Summary
The facility failed to develop and implement individualized discharge plans that incorporated the input and preferences of residents, their representatives, and the interdisciplinary team for 13 out of 27 residents reviewed for transfer and discharge. This failure was observed during a period when the facility was transferring residents to other locations due to necessary building repairs, including collapsed plumbing and other environmental issues. Despite the facility's assertion that residents were given choices of transfer locations, there was no evidence of written notices, comprehensive discharge planning, or documented interdisciplinary team meetings to discuss transfer or discharge options with the residents or their representatives. Several residents and their families reported receiving very short notice—sometimes on the same day—regarding the need to transfer, with little to no discussion of available options or involvement in the planning process. For example, one resident with anxiety and depression was transferred to a sister facility with minimal explanation and no documented care plan updates or interdisciplinary meetings. This resident expressed distress and anxiety about the rushed move and uncertainty about therapy services at the new location. Another resident with moderate cognitive impairment and a goal to return home was also moved with little notice, and his family was not offered alternative facility options closer to their home, resulting in emotional upset and reduced ability to visit. Other residents, including those with severe cognitive impairment or dementia, were similarly transferred without documented discharge planning or adequate communication with their responsible parties. Family members and residents consistently reported a lack of written notice, insufficient discussion of transfer options, and inadequate involvement in the decision-making process. The facility's records did not reflect updates to care plans or evidence of interdisciplinary team involvement in planning for these transfers, and some residents experienced emotional distress as a result of the abrupt and poorly communicated relocations.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was in the lowest position and that a fall mat was in place beside the bed, as required by the resident's care plan and facility policy. The resident, who had diagnoses including dementia, cognitive communication deficit, weakness, unsteadiness on feet, and chronic pain, was identified as a fall risk with specific interventions documented in her care plan, such as a bed alarm, floor mat, and bed in the lowest position at night. Despite these interventions, the resident's bed was left in a high position and the fall mat was not beside the bed at the time of the incident. The incident was discovered when the resident's roommate called for staff, who found the resident lying face down on the floor next to her bed. The resident reported that she had rolled out of bed and landed on her face. Staff and progress notes documented multiple injuries, including dark purple contusions to the face, neck, wrist, hand, and forearm, swelling to the eye, eyebrow, and forehead, and skin tears to the right forearm and left hand. Staff interviews confirmed that the bed was not in the lowest position and the fall mat was not in place, with one CNA stating she was overwhelmed and forgot to return the bed to the low position after care, and that the fall mat had been pushed under the bed. Further interviews with staff and the resident's family confirmed that the required fall prevention interventions were not in place at the time of the fall. The LPN on duty did not hear a bed alarm and confirmed the bed was in a high position with no fall mat beside it. The family was notified after the fall and provided photographic evidence of the resident's injuries. The facility's policy required safety interventions for residents at risk of falling, but these were not followed in this case, resulting in the resident sustaining significant injuries from the fall.
Failure to Provide Timely Written Transfer Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide timely written notification to residents and/or their representatives regarding the reason for transfer out of the facility, and also failed to notify the Ombudsman of resident transfers. This deficiency was identified for nine residents who were transferred as part of a temporary closure due to facility repairs, including plumbing and kitchen renovations. Interviews and record reviews revealed that residents and their families were often informed of the need to transfer only verbally and with very short notice, sometimes on the same day as the transfer, and did not receive the required 30-day written notice or information about appeal rights or bed-hold policies. Several residents, including those with cognitive impairments and those who were their own responsible parties, reported not receiving any written explanation for their transfer or being given adequate time to prepare. In some cases, family members or POAs were contacted by phone shortly before the transfer, and choices of alternative facilities were limited to those owned by the same corporation. Documentation in the medical records did not include evidence of written notices, discharge planning meetings, or discussions of all available options, and residents were not provided with information about their rights or the reasons for transfer in writing. The Ombudsman was not formally notified by the facility about the transfers or the temporary closure, learning of the situation only through a third party. The facility administrator and other staff acknowledged that written notices were not provided, and that the process was not treated as an emergency evacuation. Residents and their representatives expressed frustration and inconvenience due to the lack of notice and limited options, and some reported that the move made it more difficult for family members to visit. The deficiency was observed through interviews, record reviews, and direct observations of residents in their new locations.
Failure to Provide Reasonable Accommodation for Toileting Needs
Penalty
Summary
A deficiency occurred when the facility failed to promote independence and autonomy in toileting for a resident with Alzheimer's disease, dementia, anxiety disorder, and cognitive communication deficit. The resident was admitted to a room with a nonfunctioning toilet, and the bathroom remained out of order and padlocked from the time of admission. Despite the resident's ability to ambulate and use the toilet independently, she became confused due to the lack of access to a working bathroom, resulting in episodes of urinating and defecating in inappropriate places such as laundry baskets, the floor, trashcans, and her closet. Staff interviews and progress notes confirmed that the resident was provided with a bedside commode as an alternative, but she continued to experience confusion and incontinence incidents. Staff reported that the resident would get lost or confused trying to find communal bathrooms down the hallway, and required redirection and assistance. The shared bathroom attached to her room was not accessible from her side and was also nonfunctional, further limiting her options. Maintenance staff indicated that the bathroom had been out of order since July due to a clog, and it was not prioritized for repair. The Director of Nursing and other staff acknowledged that the resident remained in the room with the nonfunctioning toilet for an extended period, despite the availability of other rooms with working bathrooms. The decision to keep the resident in the room was based on proximity to the nurse's station, and there was no documentation of consideration for moving her to a more suitable room until much later. After being moved to a room with a functioning bathroom, the resident no longer experienced inappropriate toileting incidents.
Failure to Provide Timely Post-Fall Assessment and Care
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including severe cognitive impairment, malnutrition, and muscle weakness, experienced an unwitnessed fall in their room. The resident, who was independently ambulatory with a walker, was found on the floor complaining of right groin and thigh pain and was unable to stand or perform baseline activities. Despite these symptoms, the initial assessment by the LPN did not result in immediate imaging or transfer to the hospital. Instead, the LPN ordered imaging through an outside company, which was not scheduled as a stat (immediate) order. The imaging company was unable to perform the imaging on the same day due to workload, and the LPN did not notify the physician of this delay or the resident's ongoing pain and inability to bear weight. Multiple CNAs reported the resident's continued inability to perform normal functions and persistent pain to the LPN, but no further action was taken that day. The resident remained in bed, in pain, and without definitive diagnostic evaluation for over 24 hours after the fall. It was not until the following day, after the imaging was finally completed and showed a displaced right femoral neck fracture, that the resident was transferred to the hospital for further evaluation and care. Interviews with staff and review of records confirmed that the imaging order was not placed as stat, the physician was not kept informed of the delay or the resident's worsening condition, and the resident did not receive timely treatment in accordance with professional standards of practice after the fall.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident with multiple medical conditions, including chronic obstructive pulmonary disease, schizoaffective disorder, muscle weakness, and moderate protein-calorie malnutrition, experienced an unwitnessed fall in their room. Following the fall, the resident was found on the floor, complained of right inguinal and thigh pain, and was unable to perform normal functions. Despite these complaints and visible signs of pain, no pain medication was administered for several hours after the incident. The resident's care records indicated a physician order for acetaminophen to be given as needed for mild pain, and the facility's pain management policy required prompt assessment and management of pain, especially in cognitively impaired residents. However, the LPN on duty did not provide any pain medication after the fall or during her shift, even after being notified multiple times by a CNA about the resident's continued pain. The resident's family also reported that the resident expressed pain during their visit, and the MAR confirmed that no pain medication was given on the day of the fall. Imaging was eventually ordered and performed, revealing a displaced fracture of the right femoral neck. The physician was not notified of a pain assessment or the resident's inability to bear weight, and there was a delay in both imaging and pain management. The DON later confirmed that pain should have been assessed and medication administered when the resident verbalized pain, but documentation showed that pain relief was not provided until the following day.
Failure to Assess and Document Use of Positioning Devices and Alarms as Potential Restraints
Penalty
Summary
The facility failed to properly assess and document the use of adaptive equipment and pressure alarms for four residents who were reviewed for physical restraints. For one resident with frontotemporal dementia and a history of falls, a positioning device (lap buddy) and bed alarm were used without a restraint assessment or physician's order. Staff interviews revealed that the resident was physically strong but unable to intentionally remove the device, and the therapy director confirmed that recommendations for such devices were not routinely made for most residents. Another resident with dementia, traumatic brain injury, and seizure disorder was observed with a positioning device in place, but there was no restraint assessment in the medical record. The resident was unable to demonstrate the ability to remove the device independently. The MDS Coordinator stated that restraint assessments were not performed for these devices, as they were not considered restraints by the facility, and believed the devices would release when the resident stood up. Two additional residents, one with a history of fracture, aphasia, and muscle weakness, and another with anxiety, depression, and altered mental status, were both using bed and/or chair alarms as fall interventions. In both cases, there were no physician's orders or assessments for the alarms in the medical records. Staff interviews confirmed that alarms were implemented without orders or assessments, and the facility did not have a policy regarding physical restraints.
Failure to Use Person-Centered Interventions Before Administering Psychotropic Medications
Penalty
Summary
The facility failed to implement person-centered behavioral interventions and attempt less restrictive alternatives prior to administering as-needed psychotropic medications for a resident with severe cognitive impairment and multiple neuropsychiatric diagnoses. The resident was admitted with frontotemporal dementia, agitation, depression, and anxiety, and was prescribed several psychotropic medications, including clonazepam, escitalopram, haloperidol, and hydroxyzine, both on a scheduled and as-needed basis. The care plan included interventions such as allowing the resident to express feelings, encouraging participation in activities, and providing reassurance, but documentation showed these interventions were inconsistently implemented or not attempted prior to medication administration. Medication administration records indicated frequent use of as-needed psychotropic medications, including haloperidol injections and oral tablets, as well as clonazepam and hydroxyzine, often in response to behaviors such as restlessness, agitation, and combativeness. Progress notes documented that non-pharmacological interventions were either ineffective or not attempted before resorting to medication. Staff interviews revealed a lack of awareness of specific behavioral interventions for the resident, with some staff improvising activities like giving the resident a pillowcase to fiddle with. The care plan and behavior tracking records were incomplete, with several shifts lacking documentation of any interventions attempted. Further, the facility did not have policies regarding the use of psychotropic medications or chemical restraints, and there was no systematic monitoring or documentation of side effects for medications with black box warnings. The psychiatric nurse practitioner and physician confirmed that the as-needed psychotropic medication orders were continued from a previous setting, and that behavioral interventions should have been prioritized and documented before medication use. The lack of consistent, person-centered behavioral interventions and documentation, combined with the frequent use of psychotropic medications, led to the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) services 7 days a week, as required. Review of the licensed nurse schedules for June, July, and August 2025 showed that on multiple dates, there was no RN present in the facility for a full 8-hour shift. This was confirmed by the Director of Nursing, who verified the absence of RN coverage on the specified dates. Additionally, the Administrator stated that the facility did not have a policy regarding the requirement for 8 consecutive hours of RN services and instead followed state staffing guidelines. At the time of the deficiency, there were 50 residents residing in the facility.
Unsanitary Kitchen Conditions and Inadequate Cleaning Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain the kitchen floors and equipment in a safe and sanitary condition. On multiple occasions, food debris, black dirt, and dead cockroaches were found on the kitchen and dishwashing area floors. The backsplash of the stove had a buildup of grease and debris, and a significant amount of grease was present on the floor under the griddle area. The Dietary Manager, who had only been employed for about a week, reported ongoing cleanliness problems due to staff not following instructions or cleaning up after themselves, describing the kitchen as 'disgusting.' The Registered Dietitian stated an expectation for the kitchen to be clean and sanitary. At the time of the survey, 50 residents were documented as residing in the facility.
Menus Not Meeting Residents' Nutritional Needs
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met according to their individual requirements.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to provide hot, palatable, and properly prepared food to several residents, as evidenced by multiple complaints and direct observations. Four residents, all cognitively intact and with various medical diagnoses including diabetes, chronic pain, and chronic obstructive pulmonary disease, reported receiving meals that were cold, unappetizing, or improperly cooked. One resident received a cold piece of cheese pizza and had previously received burned hamburgers, providing photographic evidence of the poor food quality. Another resident refused to eat a cold meal with a breadstick that was too hard, and no substitution was offered. Test trays taken directly from the steam table confirmed that the pizza was served at 116.2°F, which was too cool, and the breadstick was hard and crunchy. Additional residents reported that scalloped potatoes served at lunch were undercooked, raw, and unpalatable. One resident, who consistently ate in her room, stated that her meal trays were always cold and that the food quality was consistently poor. Direct sampling of the scalloped potatoes from the steam table confirmed they were undercooked and crunchy. These findings were based on resident interviews, direct observation, and food temperature measurements, demonstrating a pattern of failure to ensure that food and drink were served at safe, appetizing temperatures and in a palatable condition.
Failure to Provide Prescribed Dietary Supplements and Meal Modifications
Penalty
Summary
The facility failed to provide prescribed dietary supplements and appropriate meal modifications for three residents identified as at risk for weight loss or with a history of weight loss. For one resident with severe cognitive impairment and a history of diabetes, peripheral vascular disease, and amputation, the care plan and physician orders required health shakes at lunch and supper, as well as extra butter, margarine, and sauces at all meals. However, during observation, this resident did not receive the ordered health shake, extra sauces, dressing, or butter/margarine with their meal. The registered dietitian and physician both confirmed that these supplements and modifications were expected to be provided as ordered to address weight loss. Another resident with dementia and poor dental condition was ordered a pureed diet with honey thick liquids, extra butter/margarine, extra sauces, and pudding with protein powder at lunch and supper. Observation revealed that the resident received a meal with improper texture (chunky instead of smooth puree) and was missing the required breadstick, sauce, butter/margarine, and pudding. A third resident with dementia and a history of traumatic brain injury was ordered a mechanical soft diet with extra butter/margarine, sauces, and pudding at supper. This resident received food in pieces too large and hard to chew, and did not receive the required dessert, butter/margarine, or sauce. The facility's policy requires monitoring and intervention for undesirable weight loss, including the use of supplements, but these interventions were not consistently implemented for the affected residents.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the resident did not receive adequate nutrition and hydration as required to support their health status.
Inadequate Dietary Staffing Led to Delayed Meal Service
Penalty
Summary
The facility failed to provide an adequate number of dietary staff to serve dinner in a timely manner, affecting all 51 residents. On the evening in question, two scheduled dietary aides did not report to work, and only one dietary aide was called in late, arriving at 4:00 PM for a dinner service scheduled to begin at 5:15 PM. Certified Nurse Aides (CNAs) were observed assisting in the kitchen with meal preparation, and some residents also helped by clearing trays and dishes. Multiple residents reported receiving their dinner significantly late, with some meals not served until approximately 7:30 PM. Observations confirmed that only one dietary staff member was present in the kitchen during key meal preparation times, and the first tray was not served until 6:27 PM, with hall trays starting at 6:58 PM. The facility's staffing plan, as documented in the Facility Assessment Tool, did not specify dietary staffing levels, and the policy required prompt meal service and appropriate feeding assistance. Despite the expectation that more than one staff member would be present, only one was observed in the kitchen during the dinner service. Residents interviewed were alert and oriented, and they consistently reported delays in meal service and the involvement of non-dietary staff in food preparation.
Deficient Food Safety and Sanitation Practices Following Kitchen Closure
Penalty
Summary
The facility failed to prepare and distribute food in accordance with professional standards of food safety, as evidenced by multiple observations and interviews. The kitchen was closed by the health department due to pest infestation, wastewater backup, and general cleanliness issues, resulting in the suspension of the food service permit and a directive to cease operations immediately. Despite this, staff prepared and served meals by grilling food outside and staging trays in a room without proper handwashing or dishwashing facilities. Food was handled and served in this makeshift area, which lacked basic sanitary provisions such as a handwashing sink, and food items were not consistently covered during distribution. Further deficiencies were observed in food handling practices, including staff transferring ice and glasses to residents without changing gloves or performing hand hygiene after touching potentially contaminated surfaces. Additionally, the dish machine sanitizer was found to be at an inadequate chlorine level of 10 ppm, below the required minimum of 50 ppm, and staff had not consistently tested sanitizer levels. These failures in food safety and sanitation practices had the potential to affect all 51 residents residing in the facility.
Failure to Maintain Clean and Sanitary Environment Due to Mold-Like Substance
Penalty
Summary
The facility failed to provide a clean, safe, and sanitary environment for 14 residents residing on the North Hall, as evidenced by the presence of a black substance covering approximately 50% of an air vent in the hallway near the dining area and meal tray staging room. Observations on multiple occasions revealed the black substance on both the air vent and surrounding ceiling tiles, extending to the wall. The Director of Nursing acknowledged awareness of the mold or mold-like substance and reported bringing it to the Administrator's attention, but the issue remained unaddressed as of subsequent observations. Facility policy requires environmental surfaces to be cleaned and disinfected according to CDC recommendations and OSHA standards, but these procedures were not followed, resulting in unsanitary conditions for the affected residents. No information regarding corrective or follow-up actions is included in the report.
Unpalatable and Unattractive Food Served to Residents
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for multiple residents requiring specialized diets, including pureed and mechanical soft textures. Observations revealed that pureed ham was microwaved in paper bowls, resulting in a dry, crusty, and grayish appearance before being served to several residents. Staff and the administrator acknowledged that the pureed food did not look appetizing after microwaving. Additionally, for a resident on a mechanical soft diet, ham was ground and mixed with mayonnaise due to the lack of available gravy, then microwaved and served with baked beans and applesauce. The resident later reported that the meal was insufficient and unappetizing. Other residents also received microwaved ham that appeared dry and burnt around the edges. Multiple residents expressed dissatisfaction with the quality and appearance of their meals, describing the food as "awful," "messed up," and "no good." Staff interviews confirmed challenges in preparing and serving food for all residents at the appropriate temperature and quality, citing poor planning and inadequate equipment. Facility policy requires nursing personnel or feeding assistants to inspect food trays to ensure meals are correct, palatable, attractive, and served at a safe and appetizing temperature, which was not met in these instances.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and implement new interventions to prevent elopements for a resident with dementia and a diffuse traumatic brain injury. This resident, identified as R22, was able to exit the facility multiple times without staff knowledge, including an incident where the resident walked approximately 0.8 miles from the facility down a busy street and across a highway. The facility did not investigate these incidents or implement new interventions to prevent further elopements, resulting in an Immediate Jeopardy situation. R22's medical history includes unspecified dementia, diffuse traumatic brain injury, major depressive disorder, anxiety disorder, and insomnia. The resident's Minimum Data Set (MDS) indicated a moderate cognitive impairment and a behavior of wandering that placed the resident at significant risk of reaching potentially dangerous places. Despite multiple documented elopements throughout 2024, the facility did not update R22's care plan with new interventions to address the elopement risk. Interviews with staff revealed that R22 often wandered and was not consistently supervised, especially during night shifts when staffing was insufficient to provide 1:1 supervision. The facility's alarms were not always audible in areas where staff were stationed, and there was a lack of documentation and communication regarding R22's elopements. The facility's failure to adequately supervise R22 and implement effective interventions to prevent elopements led to the Immediate Jeopardy finding.
Failure to Administer Insulin and Notify Physician
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident, resulting in significant medication errors. The resident, who was admitted with a diagnosis of type 2 diabetes mellitus, missed three doses of long-acting insulin from January 17 to January 19, leading to extremely elevated blood sugar levels. The facility did not notify the physician about the missed doses or the elevated blood sugar levels, which could have led to serious health complications. The resident's family members reported that they repeatedly asked the nursing staff about the resident's medications and insulin administration, but were told that the facility was still working on the admission process. The facility's records confirmed that the insulin was not administered due to awaiting pharmacy delivery, and there was a lack of communication between the facility and the pharmacy regarding the availability of the medication. The Director of Nursing and other staff members were unaware of the missed doses until several days later, and the physician was not informed about the resident's condition until January 21. The facility's process for handling new admissions and medication orders was not effectively implemented, leading to the resident missing critical doses of insulin and the physician not being notified of the resident's elevated blood sugar levels.
Removal Plan
- Facility has reviewed the following policies for education and implementation: Medication Order Policy - Revision made to assure IDT review and reconcile all new admission medication orders.
- DON educated by the Regional Clinical Director on the following policies and procedures: Medication Order Policy. IDT to review all new admission medication orders.
- Staff education on the following policies and procedures by DON and Regional Clinical Director and/or IDT who received train the trainer training listed above: Medication Order Policy, IDT to review all medication. Clinical department new hires will be educated by a member of the IDT that have been trained to provide the training.
- Nurses in serviced on Medication Order Policy including but not limited to medication reconciliation with hospital orders upon admission done by V2 (DON) and V39 (LPN).
- IDT team in-serviced on revised Medication Order Policy with emphasis on all new admission orders should be reviewed completed by V8 (LPN, MDS/CP Coordinator) and V2 (DON) V39 (LPN) or clinical designee.
- All resident medication order to medications on hand match back began by V3 (Regional Director of Clinical Services), V2 (DON), V39 (LPN).
Deficiency in Serving Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food at palatable and appetizing temperatures for several residents, as observed during a survey. The deficiency was identified through interviews, observations, and record reviews involving five residents. One resident, with moderately impaired cognition, reported that the food was not good and typically cold. Another resident, with intact cognition, stated that hot food items were often cold when delivered to her room. A third resident, also with moderately impaired cognition, mentioned that breakfast was often cold, though any meal could be affected. An alert and oriented resident noted that while some items like oatmeal and chili were warm, others such as eggs, waffles, and bacon were usually cold. The surveyors observed that the dietary hall cart used for delivering meals was not enclosed or insulated, leading to food sitting on the cart for over 30 minutes and not maintaining a hot temperature. During the survey, a Certified Nurse Aide delivered a tray to a resident who refused it, and the food temperature was measured, revealing that the waffles and bacon were cool to the touch. The Dietary Director acknowledged that the process of loading and delivering the large hall cart took too long, contributing to the issue of cold food being served to residents who eat in their rooms.
Unsanitary Food and Ice Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food and dietary services, as evidenced by multiple observations of unsanitary practices involving sugar and ice distribution. A container of sugar was left on the counter between the kitchen and dining room, accessible to residents. Both staff and residents used a small plastic portion cup to scoop sugar, which was then placed back into the container after use, potentially contaminating the sugar. This practice was confirmed by several residents during a Resident Council meeting, who stated they used the same cup to sweeten their beverages. Additionally, unsanitary handling of ice scoops was observed on both the south and north halls. Residents and staff were seen using the scoops to get ice, often touching the body of the scoop after handling various unclean surfaces, and then placing the scoop back into the ice cooler. This practice was confirmed by residents during a meeting, and the Dietary Director acknowledged the improper use of the sugar container and ice scoops, noting that the facility does not use individual sugar packets due to cost concerns.
Infection Control Deficiencies in Enhanced Barrier Precautions and COVID-19 Management
Penalty
Summary
The facility failed to implement proper infection control practices for Enhanced Barrier Precautions and COVID-19 infections, as recommended by the CDC, for several residents. Specifically, for Resident 47, who had severe cognitive impairment and multiple medical conditions including pressure ulcers and a feeding tube, staff did not adhere to Enhanced Barrier Precautions. Licensed Practical Nurse (LPN) V20 entered Resident 47's room, which had Enhanced Barrier Precaution signage, and administered medication and feeding through the g-tube without donning a gown, despite the requirement to do so for direct care activities. Similarly, Resident 51, who had a urinary catheter and open wounds, was on Enhanced Barrier Precautions. During wound care, LPN V4 and the Director of Nursing (DON) V2 did not wear gowns while providing care, contrary to the facility's policy and CDC guidelines. Both staff members acknowledged the oversight, recognizing that they should have donned gowns before engaging in direct care activities. Additionally, the facility failed to properly isolate residents with COVID-19. Residents 36 and 49, who tested positive for COVID-19, were observed residing in the same rooms as Residents 5 and 24, respectively, who tested negative. This was against CDC guidelines, which recommend separating residents with confirmed COVID-19 from those who are negative or have not been tested. The Regional DON admitted to being unaware of the current guidelines, which contributed to the improper cohorting of residents.
Failure to Maintain Resident Dignity During Dining Assistance
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R205, during dining assistance. R205, who has diagnoses including unspecified dementia, altered mental status, Parkinson's disease, and muscle weakness, was observed being assisted with eating by a Certified Nurse Assistant (CNA), V21, who remained standing while feeding the resident. This occurred despite the resident's Baseline Care Plan indicating a need for set-up assistance and supervision with eating, and the Minimum Data Set (MDS) documenting severely impaired cognition. During the observation, R205 consumed only about 25% of the meal before being taken out of the dining room by V21. Interviews with other CNAs revealed that the standard practice is to sit down and make eye contact with residents while assisting them with eating to ensure their dignity and safety. However, it was noted that there was no formal policy on eating assistance or dignity available when requested from V1. This lack of policy may have contributed to the inconsistency in practice observed among the staff, as some CNAs reported sometimes standing while assisting residents with eating.
Failure to Accommodate Resident Preferences for Room and Showering
Penalty
Summary
The facility failed to accommodate the preferences and needs of two residents, R55 and R51, regarding room accommodations and showering, which impacted their dignity and well-being. R55, who has vascular dementia and a history of depression, was repeatedly found sitting in a dark room without the television on, despite family members expressing concerns that this environment was not conducive to her mental health. Family members reported the issue to staff multiple times, but the situation persisted, and the administrator did not verify the family's claims about the room's condition. R51, who has moderate cognitive impairment and requires substantial assistance for showering, reported not receiving regular showers as per her preferences. Despite being scheduled for showers twice a week, R51 stated she had not received a proper shower since her admission, only being wiped down occasionally. Several CNAs confirmed they had not given R51 a shower, and there was no documentation of showers on the scheduled days. The administrator acknowledged the lack of a formal shower policy, which contributed to the inconsistency in R51's care. These deficiencies highlight the facility's failure to respect and accommodate the personal preferences and needs of residents, impacting their dignity and quality of life. The lack of attention to R55's environment and R51's bathing routine demonstrates a gap in the facility's care practices and communication with residents and their families.
Failure to Notify Physician of Missing Medications and Change in Condition
Penalty
Summary
The facility failed to notify the physician of missing medications and a change in a resident's condition. The resident, identified as R55, was admitted with diagnoses including vascular dementia and type 2 diabetes mellitus. Upon admission, there was an order for long-acting insulin, which was not administered on multiple occasions due to pharmacy delivery issues. Despite the resident's elevated blood sugar levels, the physician was not informed until several days later. Family members of R55 reported difficulties in obtaining the resident's medications, including insulin, during the initial days of admission. The facility staff repeatedly informed them that they were still working on the admission process. The medication administration record indicated that insulin was not administered on certain days, and there was a discrepancy in the records regarding the administration of insulin when it was not available in the facility. The physician, V34, confirmed that he was not notified about the resident's insulin or blood sugar levels until several days after the admission. The Director of Nursing (DON) and other nursing staff acknowledged that the physician should have been contacted regarding the missed doses of insulin and the elevated blood sugar levels. The facility's failure to communicate these critical issues to the physician contributed to the deficiency identified in the report.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure privacy for a resident during wound care and urinary catheter treatment. The resident, who has moderate cognitive impairment and is dependent on assistance for toileting hygiene, lower body dressing, and bed mobility, was exposed during these procedures. The resident's care plan noted risks for skin breakdown and the presence of a Foley catheter, with open areas on the buttocks requiring wound care. During the wound care procedure, the resident's lower body was exposed, and the window blinds or curtains were not drawn, leaving the resident visible to anyone outside. Similarly, during urinary catheter care, the resident was again exposed without the privacy curtains or blinds being used. The resident expressed distress over the lack of privacy, feeling dehumanized by the staff's actions. These observations were made by surveyors during their review of the facility's practices.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R55, from verbal abuse by a staff member. R55, who has vascular dementia and type 2 diabetes mellitus, was admitted to the facility and was reported to have been verbally abused by a nurse on the first day of admission. Family members, V35 and V37, witnessed the nurse yelling at R55 and using inappropriate language, telling her to "sit her ass down and stay down." Despite reporting the incident to the facility staff, no immediate action was taken until a care plan meeting was held. The facility conducted an investigation into the allegations, but the administrator, V1, stated that the abuse could not be substantiated due to a lack of evidence from staff and resident interviews. The nurse involved, V46, denied cursing at the resident and claimed to have only educated R55 about safety concerns. The investigation included interviews with the resident, family members, and staff, but no other witnesses corroborated the family's account of the incident. The facility's documentation indicated that the resident did not report any cursing but felt the nurse was too rough when assisting her. The facility's final report concluded that the incident was a misunderstanding due to cultural differences, as the nurse was from the Philippines and the resident had difficulty understanding her. The investigation found no prior complaints against the nurse, and the resident showed no signs of emotional distress or injury. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, including verbal and mental abuse, but the investigation did not substantiate the allegations of inappropriate staff behavior.
Failure to Substantiate and Address Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of staff-to-resident verbal and mental abuse was accurately concluded and did not implement corrective actions to prevent further potential abuse. The incident involved a resident with vascular dementia and type 2 diabetes mellitus, who was moderately cognitively impaired. Family members reported witnessing a nurse yelling at the resident and using inappropriate language, but the facility's investigation did not substantiate the claims due to a lack of corroborating evidence from other staff and resident interviews. The resident's family members reported the incident to the facility, but no immediate action was taken until a care plan meeting was held. During the meeting, the administrator informed the family that the nurse involved would not face any consequences as she was soon leaving the country. The family expressed concerns about the nurse's behavior, but the facility's investigation concluded that the incident was a misunderstanding due to cultural differences, and the nurse returned to work. The facility's documentation indicated that the resident did not exhibit signs of emotional distress or injuries, and the resident reportedly did not confirm the use of curse words by the nurse. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and outlines the process for protecting residents from such incidents. However, the facility's handling of the situation did not align with these policies, as the investigation was deemed insufficient and corrective actions were not implemented to prevent future occurrences.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with diagnoses including a fracture of the femur, falls, epilepsy, and muscle weakness. The resident's medical record did not document a baseline care plan. The Director of Nurses stated that the nurse responsible for completing the baseline care plan upon the resident's admission had forgotten to do it, and it was being completed at the time of the interview.
Failure in Proper Catheter Care for a Resident
Penalty
Summary
The facility failed to provide proper indwelling urinary catheter care for a resident, identified as R47, who was part of a sample of 42 residents reviewed for catheter care. R47's medical history included conditions such as dysphagia, muscle weakness, gastrostomy status, hyponatremia, colostomy, and a stage 4 pressure ulcer in the sacral region. The resident was also noted to have severely impaired cognition with a BIMS score of 5 and was dependent on assistance for toileting and repositioning. The care plan for R47 highlighted a risk for urinary tract infections related to the use of an indwelling catheter. During an observation, an LPN identified as V20 performed catheter care for R47 but failed to follow the facility's policy and standard practices. V20 used soapy water to clean the resident's groin and catheter area but did not rinse the area with clean water afterward, nor did she pat the area dry, as required by the facility's catheter care policy. The policy specifically states that the area should be rinsed and dried well after cleaning with soap and water to reduce the incidence of infection. This oversight in the catheter care procedure was acknowledged by V20 when questioned by the surveyor.
Failure to Check Gastrostomy Tube Placement Before Administration
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the checking of gastrostomy tube placement before administering medications, flushes, or feedings for a resident. The resident, who was admitted with diagnoses including dysphagia, muscle weakness, and gastrostomy status, was observed to have severely impaired cognition and was dependent on eating. The care plan indicated the resident was at risk for nutritional deficit and was on a tube feeding regimen. However, during observations, a Licensed Practical Nurse (LPN) administered medications and tube feedings without checking the placement of the gastrostomy tube, contrary to the facility's policy. Interviews with the nursing staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the facility's procedure required checking the placement of the gastrostomy tube by aspirating stomach contents before any administration. The LPN admitted to not checking the placement, relying instead on the previous shift's check. The DON and a Regional Nurse emphasized that the facility no longer uses the method of pushing air into the stomach to check placement, which the LPN had mentioned. The facility's policy, revised in March 2025, clearly outlines the procedure for confirming tube placement to prevent aspiration, which was not followed in this instance.
Neglect Leads to Resident's Decline and Hospitalization
Penalty
Summary
The facility failed to ensure a resident was free from neglect, resulting in significant harm. The resident, who was cognitively intact and at risk for pressure ulcers, was not properly assessed or treated for skin breakdown upon returning from a hospital stay. Despite hospital discharge instructions to discontinue certain psychotropic medications, the facility continued to administer Haldol and Clonazepam without a physician's order, leading to the resident's somnolence and further decline in condition. The resident developed 15 new wounds, including pressure ulcers, and was eventually transferred back to the hospital for altered mental status and possible sepsis. The facility's staff did not perform adequate skin assessments or implement necessary interventions to prevent pressure ulcers. The resident's care plan indicated a need for regular skin checks and interventions, but these were not followed. The resident's skin condition deteriorated significantly, with multiple pressure injuries identified upon hospital readmission. Additionally, the facility failed to provide adequate oral care, resulting in a severe buildup on the resident's tongue, further indicating neglect. Communication breakdowns among the facility's staff contributed to the neglect. Nurses failed to clarify medication orders and did not notify the physician of the resident's condition changes. The Director of Nursing acknowledged the lack of assistance and oversight in managing the resident's care, leading to missed assessments and treatment orders. The facility's policies on pressure ulcer care, medication administration, and change in resident condition were not adhered to, resulting in the resident's decline and subsequent hospitalization.
Failure to Provide Adequate Oral Care for Residents
Penalty
Summary
The facility failed to ensure proper oral care for two residents, R2 and R12, leading to significant oral health issues. R12, who was cognitively intact and required setup or cleanup assistance with oral care, was found to have a severe buildup of hardened yellow/brown coating with cracking and fissures on the tongue due to lack of oral care. The resident's hospital records indicated a dry mouth with yellow crusts on the tongue and palate, and a photograph showed a dry, scaly, cracking residue on the tongue. Interviews with staff revealed that oral care was not routinely provided, and there was a lack of specific focus or interventions for oral care in R12's care plan. R2, also cognitively intact and requiring setup or cleanup assistance with oral care, reported that her teeth were not brushed, and staff never provided her with oral care items. Staff interviews confirmed that oral care was not consistently provided, and there was uncertainty about the availability of oral care supplies. R2's care plan similarly lacked documentation of a focus area or interventions related to oral care. The facility's policy on mouth care aimed to keep residents' oral tissues moist and prevent infections, but staff interviews indicated that oral care was not prioritized. The facility's failure to provide adequate oral care resulted in physical and emotional discomfort for the residents, as evidenced by the condition of R12's mouth and R2's reports of neglect in oral hygiene.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess, treat, and implement interventions to prevent pressure ulcers for several residents, leading to significant skin breakdowns. One resident, identified as R12, was admitted with multiple diagnoses including a fracture, diabetes, and schizophrenia, and was at risk for pressure ulcers. Despite being at moderate to high risk for skin breakdown as indicated by the Braden Scale, the facility did not conduct thorough skin assessments or implement necessary interventions. R12 developed multiple pressure ulcers, including Stage 2 and Stage 3 ulcers, and deep tissue injuries, which were not properly documented or treated by the nursing staff. The facility's records showed a lack of physician notification and treatment orders for these conditions. Another resident, R1, was admitted with a Stage III pressure ulcer and was at moderate risk for further skin breakdown. Despite observations of new open areas and mushy heels, the facility failed to document these findings or obtain treatment orders. The Director of Nursing admitted to forgetting to implement necessary orders for the newly identified areas. Similarly, R2, who required substantial assistance and was at moderate risk for skin breakdown, had a new area of concern on her heel that was not properly documented or assessed. The facility's records did not reflect appropriate interventions or physician notifications for these issues. R3, who had a severe cognitive deficit and was at low risk for pressure ulcers, was also affected by the facility's inadequate care. Despite having a care plan that included elbow pads for prevention, R3 was observed without them, and a wound on the elbow was not properly documented or treated. The facility's policy on pressure area care was not followed, as assessments and documentation were incomplete, and physician notifications were not consistently made. These failures in care and documentation contributed to the development and worsening of pressure ulcers among the residents.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered per current standards of practice for several residents. For one resident, the LPN prepared medications by mixing liquid valproic acid and sucralfate, and crushed pills without performing hand hygiene. The resident, who was cognitively intact and had a gastrostomy tube, self-administered the medications without proper supervision or a documented self-administration assessment. Additionally, there was no physician order on how to administer the medications via the G-tube. Another resident with moderate cognitive deficit received gabapentin from the LPN, who handled the medication without performing hand hygiene or wearing gloves. Similarly, a cognitively intact resident was left with medications on the bedside table without supervision, and there was no order for self-administration. The LPN did not observe the resident taking the medications and failed to perform hand hygiene afterward. Further deficiencies were observed with other residents, including leaving the medication cart unlocked and unattended, and handling medications without proper hygiene practices. The Director of Nurses acknowledged the expectation for licensed nurses to follow policies and procedures, including infection control measures, and noted the absence of a physician's order or assessment for self-administration in one resident's medical record.
Failure to Discontinue Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not discontinuing psychotropic medications as ordered by the physician. The resident, who was admitted with multiple diagnoses including schizophrenia and bipolar disorder, was prescribed psychotropic medications such as Clonazepam and Haldol. Despite the hospital's instructions to discontinue these medications upon the resident's discharge, the facility continued to administer them. The resident's behavior tracking records indicated various behaviors, but the hospital records showed that the resident had no psychiatric issues during the hospital stay, leading to the discontinuation of Haldol and Clonazepam. However, upon returning to the facility, these medications were still administered multiple times. The facility's staff, including the RN responsible for readmitting the resident, failed to clarify the medication orders, leading to the continued administration of the discontinued medications. Interviews with facility staff revealed a lack of communication and assumption of actions taken by others. The RN who readmitted the resident noted the discontinuation in the progress notes but did not ensure the orders were updated. The night shift RN did not verify the medication orders, and the Psychiatric Nurse Practitioner was not informed of the hospital's discontinuation of the medications. This miscommunication and lack of verification resulted in the resident receiving unnecessary medications, contrary to the hospital's discharge instructions.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feeding as ordered for a resident with a gastrostomy tube, leading to a deficiency. The resident, who had diagnoses including dysphagia and adult failure to thrive, was supposed to receive continuous tube feeding as recommended by the dietitian. However, the facility continued to administer bolus feedings due to a lack of signed orders from the resident's Primary Care Physician (PCP) and the absence of compatible tubing for continuous feeding. The report highlights communication and documentation issues within the facility. The resident's State Guardian had requested a change from bolus to continuous feeding due to the resident's decline and weight loss. Although the dietitian recommended this change, the order was not signed by the PCP, and the facility did not have the necessary tubing for continuous feeding. Additionally, there were discrepancies in the documentation of the tube feeding orders, with nursing staff unsure of which formula was being administered and why there were two different orders in the resident's Electronic Medical Record (EMR). The facility's Director of Nursing (DON) and other staff members were unaware of the issues with the tube feeding administration. The DON was not informed that the nurse responsible for the resident's care was not administering the 6:00 AM feedings. Furthermore, the facility lacked a system to track and ensure that diet change recommendations were sent to and returned from the resident's PCP. This lack of coordination and oversight contributed to the failure to provide the resident with the appropriate tube feeding as ordered.
Narcotic Medication Documentation and Reconciliation Deficiencies
Penalty
Summary
The facility failed to accurately document narcotic medication administration and reconcile narcotic medication counts according to professional standards of practice. This deficiency was identified for four residents, with discrepancies in the documentation and administration of narcotic medications such as hydrocodone/acetaminophen and oxycodone. The facility's narcotic diversion policy and documentation policies were not adhered to, leading to potential medication diversion and inaccurate medication records. For Resident 5, the facility could not locate a card of 30 hydrocodone/acetaminophen tablets delivered on a specific date, and the Controlled Drug Receipt/Record/Disposition Form was missing. The Director of Nursing (DON) suspected narcotic diversion by a Licensed Practical Nurse (LPN) but did not report or investigate these suspicions. The LPN was the only nurse administering the medication to Resident 5, and there were discrepancies between the Controlled Drug Receipt/Record/Disposition Form and the Medication Administration Record (MAR). Similar issues were found with Residents 1, 4, and 6, where the LPN was the sole nurse administering narcotic medications, often earlier than ordered, and without proper documentation on the MAR. The facility's policies required documentation of medication administration, including the date, time, dosage, and results, but these were not consistently followed. The facility's failure to adhere to its narcotic diversion policy and documentation procedures resulted in unaccounted medications and potential risks to resident safety.
Misappropriation of Resident Property and Medication Discrepancies
Penalty
Summary
The facility failed to prevent the misappropriation of resident property, specifically controlled medications, for six residents. The investigation revealed that a Licensed Practical Nurse (LPN), identified as V3, was the only nurse administering narcotic medications to several residents, and there were discrepancies in the medication records. For instance, R5's hydrocodone/acetaminophen tablets delivered on a specific date were missing, and the Controlled Drug Receipt/Record/Disposition Form was not found. The Director of Nursing (DON) had suspicions about V3 diverting narcotic medications but did not report these suspicions or conduct an investigation. Residents reported suspicions of not receiving their pain medications. R7, who was cognitively intact, reported to the DON that V3 did not provide her pain medication as claimed. Despite R7's allegations and documentation of medication administration discrepancies, no investigation was conducted. Similarly, R6 suspected V3 of stealing her pain medication, and her caretaker witnessed V3 attempting to administer incorrect medication. R6's records showed discrepancies between documented administration and actual receipt of medication. Additionally, R3 reported a missing laptop, which was not thoroughly investigated by the facility. The facility's policies on abuse prevention, narcotic diversion, and controlled substance management were not followed, as evidenced by the lack of immediate reporting, investigation, and reconciliation of medication discrepancies. The facility's failure to adhere to these policies resulted in the misappropriation of resident property and potential medication diversion.
Failure to Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of property within the required time frames for several residents. One resident, who was cognitively intact, reported a missing laptop to the administrator, who acknowledged the report but failed to initiate an investigation or file a report until prompted by the surveyors. The administrator admitted to forgetting about the incident, and no action was taken until the surveyors' intervention. Another resident, also cognitively intact, had an allegation of verbal abuse reported by their power of attorney to the Director of Nursing. Despite the report being witnessed by another staff member, the Director of Nursing dismissed the allegation, stating disbelief in the claim. The administrator was aware of the report but did not file it due to the resident denying the allegation when interviewed. Consequently, no investigation was initiated, and the alleged perpetrator was not suspended pending an investigation. Additionally, a physical therapy assistant reported an incident involving the Director of Nursing raising her voice in front of a resident during a telehealth visit. The incident was reported to the assistant's supervisor, who informed the administrator. However, the administrator did not consider the incident as abuse and did not report it to the Illinois Department of Public Health. Furthermore, another resident suspected a nurse of not administering pain medication and reported it to a staff member. The Director of Nursing was aware of suspicions regarding the nurse's conduct but did not report them or initiate an investigation.
Failure to Investigate Abuse Allegations Timely
Penalty
Summary
The facility failed to initiate and complete investigations of abuse allegations in accordance with required time frames for several residents. One resident reported a missing laptop, which was not investigated promptly. The resident had provided the receipt and serial number to the staff, but the investigation was delayed, and the laptop was not found. The facility eventually reported the incident to the Illinois Department of Public Health and the local police department, but the initial delay in investigation was a deficiency. Another resident's Power of Attorney reported an allegation of verbal abuse by a CNA, which was initially dismissed by the Director of Nursing. The allegation was not immediately investigated, and the CNA was not suspended pending investigation. The facility later conducted interviews with the resident, who denied the abuse, but the initial failure to take the allegation seriously and conduct a timely investigation was a deficiency. Additionally, a physical therapy assistant and therapist reported an incident where the Director of Nursing yelled at them in front of a resident. The incident was reported to the facility administrator, but no investigation was initiated as it was not considered abuse. Furthermore, a resident suspected a nurse of not administering pain medication and reported it to the staff. However, no investigation was conducted, and the nurse continued to work without suspension. These failures to investigate and address allegations of abuse and neglect in a timely manner highlight deficiencies in the facility's handling of such incidents.
Failure to Provide Timely and Dignified Care
Penalty
Summary
The facility failed to provide timely and dignified care for two residents, R1 and R3, as observed through interviews and record reviews. R1, who has a history of spinal stenosis, obesity, and anxiety, among other conditions, reported waiting 45 minutes for assistance to the restroom after pressing the call light. This delay led to an incontinent episode in her bed. R1's care plan emphasizes the need for prompt response to requests for assistance and ensuring her call light is within reach, but these measures were not effectively implemented. Additionally, R1 mentioned that her walker and wheelchair were placed out of her reach, preventing her from getting up alone, which is against the advice due to her fall risk. The facility's administrator confirmed R1's need for assistance with mobility and transfers. R3 also reported experiencing long wait times for call light responses, particularly on Monday and Tuesday day shifts, with waits extending up to 45 minutes. R3's medical records indicate that she is cognitively intact and dependent on two or more staff members for transfers out of bed. The facility's procedure for answering call lights states that residents' calls should be answered as soon as possible, but this guideline was not followed, leading to delays in providing necessary assistance to R3. These deficiencies highlight a failure in the facility's ability to respond promptly to residents' needs, compromising their dignity and care quality.
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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