Integrity Hc Of Marion
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Illinois.
- Location
- 1301 East Deyoung, Marion, Illinois 62959
- CMS Provider Number
- 145863
- Inspections on file
- 40
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Integrity Hc Of Marion during CMS and state inspections, most recent first.
The facility failed to respond to call lights in a timely manner for multiple residents, including one who returned from a hospital stay to find a wet bed and waited an extended period after a family member activated the call light for assistance. Several residents filed grievances reporting long delays in call light response, including reports that call lights took over 30 minutes to be answered, that staff turned off call lights without returning, and that a resident soiled herself after a call light allegedly went unanswered for several hours. A family member reported unsuccessful attempts to reach the Administrator about these concerns. The acting DON and the Administrator both stated that call lights should be answered as quickly as possible, but neither specified a firm time standard, and both acknowledged that the facility did not have a call light policy.
A resident who was cognitively intact returned from the hospital and was moved to a different room for isolation that had not been cleaned after the prior occupant left. The resident and a family member reported dirty beds, dirt on the floor, used oxygen tubing on a chair, food crumbs on an adjacent bed, a cupcake left on the overbed table, and a toilet with brown stains resembling feces. The Housekeeping Supervisor and facility leadership acknowledged that rooms are expected to be cleaned daily and before a new resident is placed, but a miscommunication among housekeeping staff led to the room not being cleaned prior to the resident’s admission.
The facility did not serve meals at scheduled times, resulting in residents waiting extended periods for food, with some not receiving trays until staff intervened. Staff interviews confirmed that meal delays were common, often due to staffing shortages, and nursing staff expressed concern for diabetic residents needing timely meals with insulin. Residents were observed eating snacks to compensate for late meals, and posted meal times were not consistently followed.
A resident with multiple medical conditions was subjected to verbal abuse and profanity by a dietary aide after requesting an alternative meal. The incident was reported to nursing and dietary management, but the administrator, who was also the Abuse Coordinator, did not investigate or report the event as abuse, instead treating it as a customer service issue. Facility policy defined such language as verbal abuse, but the required procedures were not followed.
A resident with multiple medical conditions and intact cognition reported being verbally abused by a dietary aide, who used profane language and refused a food request. Staff, including an LPN and the dietary manager, were made aware and collected statements, but the administrator, acting as Abuse Coordinator, did not report the incident to the State Agency or law enforcement as required, instead treating it as a customer service issue. Facility policy for reporting and documenting abuse allegations was not followed.
A resident with multiple health conditions reported that a dietary staff member used profane language and refused to prepare a requested meal. Multiple staff corroborated the incident, but the administrator, despite being the abuse coordinator, did not conduct a formal investigation or report the event as required by facility policy. The lack of a thorough investigation and proper documentation led to a deficiency finding.
Three dependent residents with significant cognitive and physical impairments did not receive timely incontinence care or repositioning as required, with staff and resident interviews confirming that care was missed due to disruptions such as late meal service. Facility policy required care every two hours, but this was not consistently provided.
A resident with significant mobility limitations and multiple health conditions was not provided with required pressure-relieving devices or repositioned as per facility policy, resulting in the development of a pressure injury. Staff failed to accurately assess the resident's risk and did not implement necessary interventions, despite clear indications of high risk for skin breakdown.
A resident with intellectual disabilities, schizophrenia, and a documented risk for wandering eloped from the facility after exhibiting exit-seeking behavior. Despite a care plan noting elopement risk, the resident was not wearing an electronic monitoring device and was able to leave undetected. Staff initiated a search and notified police after discovering the resident missing, and the resident was later found safe at a family member's home.
Surveyors found that the dry food storage area was contaminated with mouse droppings and evidence of rodent entry, including a hole in the wall and debris, despite previous pest control efforts. The facility lacked a specific dry storage policy, and 94 residents were present at the time.
Multiple residents and staff reported and observed mice and evidence of rodent activity throughout the facility, including in resident rooms and food storage areas. Mouse droppings, open food, and structural access points were noted, and staff acknowledged the widespread presence of mice. The facility's pest control measures were ineffective in preventing or eliminating the infestation.
A resident who required pain management did not receive safe and appropriate interventions, resulting in a deficiency related to inadequate pain management services.
Multiple residents with varying medical conditions did not have accessible or adequately refreshed water in their rooms, with some unable to reach their pitchers and others reporting that water was only provided upon request or not refreshed regularly. Staff interviews confirmed inconsistent practices in passing water, and the facility lacked a policy to ensure hydration needs were met.
A working call system was not available in each resident's bathroom and bathing area, as observed during the survey. This deficiency was noted based on the lack of required equipment to allow residents to request assistance in these areas.
A resident with a recent right femur fracture and mobility deficits was unable to access a functioning call light system and had to rely on a bell that was not within reach, resulting in delayed assistance. Staff confirmed the call system had been down for several days, and bells were used as a substitute, but these were not always accessible or effective in alerting staff to residents' needs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident admitted for short-term IV antibiotics, who was also a federal inmate, was kept under constant guard, handcuffed to the bed, and denied access to personal property, visitors, facility activities, and communication such as telephone use. The facility did not have policies or a care plan addressing these restrictions, resulting in a failure to protect and promote the resident's rights to dignity, self-determination, and communication.
A resident with multiple comorbidities developed unstageable ulcers on both heels that were not properly identified, assessed, or treated according to physician orders. There were significant lapses in wound documentation, delayed implementation of heel protection, and missed opportunities for infection management. The resident's condition worsened, leading to hospitalization for sepsis and gangrene, surgical debridement, and eventual death from septic shock.
A resident with multiple chronic pain conditions experienced ongoing severe pain that was not adequately managed, despite having several pain medications ordered. Pain assessments were inconsistently documented, and staff often relied on casual conversations or chart reviews rather than thorough evaluations. The resident reported daily pain that interfered with mobility and activities, while staff expressed limited options for further pain control and were sometimes unaware of the resident's diagnoses. The facility did not follow its own pain management policy, resulting in unmanaged pain and decreased quality of life.
Multiple residents who required assistance with daily activities experienced significant delays in call light responses, especially on weekends, due to insufficient staffing. Staff interviews and schedule reviews confirmed that CNAs and nurses were often assigned to cover large numbers of residents alone, making it difficult to provide timely care. The DON acknowledged the lack of a call light policy and agreed that current response times were not acceptable.
Surveyors identified failures in food storage and sanitation, including a large ice buildup in the freezer causing food to fall onto the floor, improper handling of drinking glasses by a dietary aide after touching multiple surfaces, and use of a sanitizer solution below required strength by another aide who was unaware of proper levels. These issues had the potential to affect all 96 residents in the facility.
Surveyors found that several residents with complex medical conditions were served ham portions smaller than the 3 ounces specified by the dietician-approved dietary spreadsheet. Staff confirmed the portions were insufficient and that the facility had the means to provide the correct amount. Ongoing concerns were also documented regarding inconsistent food portions and meal ticket errors, particularly during dinner and weekends.
Several residents received lunch trays with ham served below the required hot holding temperature, as confirmed by thermometer readings and resident complaints that the food was not hot. The dietary manager served the food without reheating, contrary to facility policy that mandates hot foods be held at 136°F or above until served.
Four residents with orders for mechanical soft diets were served food items, such as large pieces of cauliflower, that did not meet their prescribed texture requirements, and one resident did not receive a required PB&J sandwich. These residents had complex medical conditions requiring dietary modifications, but the facility did not consistently follow physician orders or care plans, as confirmed by meal observations and ongoing resident council concerns about meal service accuracy and consistency.
Multiple residents who were dependent on staff for assistance with toileting, hygiene, and mobility experienced significant delays in call light response, with some waiting over an hour for help. Staff and residents attributed these delays to inadequate staffing, especially on weekends and when only one CNA was assigned to large hallways. The DON confirmed there was no call light policy and acknowledged that current response times were not acceptable.
Two residents were admitted without having advance directives or POLST forms formulated or offered as required by facility policy. One resident with severe cognitive impairment had no documentation of code status or advance directives in the EHR or care plan, and staff could not identify the resident's wishes in an emergency. Another resident, who was cognitively intact, had a care plan indicating full code status but lacked a documented advance directive or POLST form until after surveyor inquiry.
A resident with severe cognitive impairment reported being hit by another resident known for combative behavior and wandering. Another cognitively intact resident witnessed the incident and called for help. Staff were aware of the situation but did not document or report the allegation of abuse to the Administrator as required, resulting in a delayed investigation.
Two residents with significant medical needs were transferred to the hospital, but neither they nor their representatives received a copy of the facility's bed hold policy as required at the time of transfer. Documentation in the medical records and nurse's notes did not show that this notification was provided during their hospitalizations.
A resident with multiple mental health diagnoses did not have a current PASSR Level 2 screening in place after the previous short-term approval expired. The required screening was missed due to staff oversight, despite the resident's ongoing mental health needs documented in the care plan and assessments.
Three residents with cognitive and physical impairments did not receive necessary assistance with meal setup and eating, resulting in their inability to access or consume their food until staff intervention occurred. Staff failed to remove lids, open condiments, or provide encouragement as required by facility policy and resident care plans.
A resident with multiple diagnoses, who was cognitively intact, was found storing discontinued medications at the bedside after an LPN attempted to administer a medication that had already been discontinued. The resident, not authorized to self-administer, kept the pills in a medication cup after identifying the error. Facility policy requires only licensed staff to administer medications and prohibits self-administration without proper authorization, but these procedures were not followed, resulting in the deficiency.
A resident with multiple medical conditions and moderate cognitive impairment did not receive a required meal and was served a meal intended for another resident, resulting in meal service errors and another resident missing their lunch. Ongoing concerns about incorrect meal tickets and inconsistent portions were also documented by the resident council.
Three residents did not receive meals in accordance with their documented dietary preferences and restrictions, including being served disliked or restricted items such as apple juice, cauliflower, and drinks with ice. Residents expressed dissatisfaction, and facility records showed ongoing concerns about dietary tickets not being properly followed, despite policies requiring identification of food preferences.
Two residents with orders for adaptive eating utensils, including built-up and weighted utensils, did not consistently receive the required equipment during meals. Both residents, who had complex medical conditions such as dementia, Parkinson's disease, and muscle weakness, were observed receiving regular utensils instead of the prescribed adaptive devices. Dietary staff acknowledged that kitchen staff are responsible for ensuring adaptive equipment is provided, and facility records indicated ongoing issues with meal tickets being read incorrectly.
A resident with a history of self-inflicted burns was inadequately supervised, resulting in second-degree burns from hot water. Despite being dependent on staff for assistance, the resident was given hot water in a pitcher, leading to an accident. The facility's policy required adjusting interventions based on resident needs, which was not effectively implemented, contributing to the incident.
A resident was mistakenly given another resident's medications due to a nurse's failure to use two identifiers for proper identification. The nurse did not notify the physician about the unavailability of the resident's prescribed medication for restless leg syndrome. The facility's policy requires using two identifiers, which was not followed in this case.
A resident at high risk for falls due to multiple health conditions experienced falls because the facility failed to implement care plan interventions, such as placing fall mats at the bedside. Despite documented incidents of falls and injuries, staff were unaware of the missing fall mats, leading to a deficiency identified by surveyors.
The facility failed to provide prescribed dietary supplements and double portions for several residents, including one with severe cognitive impairment. Observations showed that meal trays lacked required portions and supplements, and the dietary staff did not communicate effectively to ensure dietary orders were followed. This issue was noted for multiple residents, indicating a systemic problem.
The facility failed to label insulin with open dates for four residents, leading to a deficiency in medication management. Insulin vials for residents with conditions like type 2 diabetes were found open without dates, confirmed by an LPN who stated insulins should be dated and discarded after 30 days if not. The DON expected staff to label insulin but was unsure of the facility's policy. The facility's policy required proper storage and noted insulin expires 28 days after opening.
The facility failed to adhere to its recipes for pureed diets, affecting 13 residents. The Dietary Manager prepared pureed pasta salad and cheeseburgers using unmeasured amounts of water and thickening agents, contrary to the specified recipes. The Registered Dietitian confirmed that staff were expected to follow these recipes to meet residents' dietary needs.
A resident with multiple diagnoses, including Parkinson's Disease and Type 2 Diabetes, did not receive prescribed daily wound care for scalp and facial wounds as per physician's orders. The Treatment Administration Record showed missed treatments, and both the Wound Care Physician and DON were unaware of the inconsistency in care.
A resident with a history of falls and gait/balance problems fell while getting off a transit bus, resulting in a left patellar fracture. The facility failed to ensure the resident used a walker, did not perform a full body assessment or notify the physician immediately after the incident, and did not send the resident to the ER until the following day when her pain worsened.
Failure to Respond Timely to Resident Call Lights and Lack of Call Light Policy
Penalty
Summary
The deficiency involves the facility’s failure to answer resident call lights in a timely manner for six residents, affecting their right to a dignified existence, self-determination, communication, and exercise of rights. One cognitively intact resident (BIMS score 13) reported that upon returning from a hospital stay and being moved to a new room, his bed sheets and mattress were wet; his daughter activated the call light to request fresh linens, and he recalled that it took well over 15 minutes for staff to respond. The daughter stated she timed the response using her phone, initiating the call light at 8:20 p.m. and noting that staff did not respond until 9:00 p.m., and she identified the specific date this occurred. She also reported unsuccessful attempts to reach the Administrator about concerns with call light response times, describing repeated “phone tag” and eventually discontinuing her efforts. Additional evidence of delayed call light response was documented through multiple resident grievance forms. One resident reported that it took a long time for staff to answer call lights on the night shift, while another stated that CNAs were not answering her call light in an appropriate amount of time. Another resident reported that nursing staff were not timely in answering his call light, and a further grievance documented that a resident’s call light took over 30 minutes to be answered and that when staff did come, they turned the call light off and did not return to address the issue. In another case, a resident’s POA complained that the resident had soiled herself because her call light had not been answered in four hours. When interviewed, the Regional Director of Clinical Operations/Acting DON stated he had not received recent complaints about call light response times, believed call lights should be answered as quickly as possible, and considered 15 minutes an appropriate maximum, while acknowledging the facility had no call light policy. The Administrator similarly reported not being aware of complaints, stated call lights should be answered as quickly as possible depending on circumstances, and confirmed there was no facility call light policy.
Resident Placed in Unclean Room Following Hospital Return
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment when a newly admitted resident was placed into a room that had not been cleaned after the prior occupant left. The resident, who was cognitively intact with a BIMS score of 13, reported that upon returning from a hospitalization and being moved to a different room for isolation, the beds in the new room were dirty and did not appear to have been cleaned. The resident’s family member corroborated this, stating that the room did not appear to have been cleaned or sanitized, noting dirt on the floor, used oxygen tubing on a chair, a cupcake in a container on the overbed table, and food crumbs on the empty bed next to the resident. The family member also reported that the private bathroom toilet appeared unclean, with brown stains resembling feces on the porcelain bowl. The Housekeeping Supervisor stated that resident rooms are supposed to be cleaned daily, including wiping high-touch surfaces with sanitizer, sweeping and mopping floors, emptying trash, and cleaning lavatories and toilets, and that mattresses and bed frames are cleaned twice weekly on shower days. She explained that due to a miscommunication, the housekeeper responsible for the room believed there was more time to clean it, went to lunch, and by the time they returned, the resident had already been placed in the room, which had not been cleaned between the prior resident’s discharge and the new resident’s admission. The Regional Director of Clinical Services/Acting DON and the Administrator both stated that rooms should be cleaned daily and that the room should have been cleaned before the resident was placed there, with the Administrator acknowledging there had been a complaint about this specific room not being cleaned prior to the resident’s return from the hospital. An undated “Deep Cleaning a Room” checklist describes extensive cleaning steps but does not change the fact that the room was not cleaned before the resident’s placement.
Failure to Serve Meals Timely and Consistently to Residents
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner, as required to meet residents' needs, preferences, and requests. Multiple residents reported and were observed experiencing significant delays in meal service, with some meals being served well past the scheduled times. On several occasions, residents were seen waiting in the dining room for extended periods before receiving their meals, and some resorted to eating snacks such as chips due to hunger. Staff interviews confirmed that meal delays were a recurring issue, often attributed to staffing shortages and operational challenges in the kitchen. The facility's posted meal times were not consistently adhered to, with documented instances of lunch and supper being served over an hour late. Additionally, there were instances where residents did not receive their trays at all until staff intervention occurred. One resident was observed preparing to leave the dining room without supper, believing she would not receive a tray, until a staff member intervened to provide her meal. Another resident was also reported to have not received a tray until prompted by staff. Nursing staff expressed concerns about the impact of these delays, particularly for diabetic residents who require timely meals in relation to insulin administration. The deficiency was substantiated through direct observation, resident and staff interviews, and review of facility records.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including osteomyelitis, type 2 diabetes with skin complications, traumatic amputation, hyperlipidemia, bipolar disorder, and hypertension, was subjected to verbal abuse by a dietary aide/cook. The resident, who was cognitively intact, requested a grilled cheese sandwich as an alternative meal. The dietary aide responded with profanity, refused to prepare the sandwich, and dismissed the resident's request in a derogatory manner. Multiple staff statements corroborated that the aide used inappropriate language and refused service to the resident, and that similar issues had occurred with this staff member previously. The incident was promptly reported by the resident to a nurse, who then notified the dietary manager and the administrator. The dietary manager collected statements from those involved and sent the staff member home. However, the administrator, who also served as the facility's Abuse Coordinator, did not report the incident as abuse, instead categorizing it as a customer service issue. No formal investigation into whether the incident constituted verbal abuse was conducted by the administrator, despite being notified of the situation and receiving documentation from the dietary manager and nursing staff. Facility policy defined verbal abuse as the use of disparaging or derogatory language toward residents. The administrator acknowledged being aware of the incident and the staff member's conduct but did not review the collected statements or initiate an abuse investigation. The lack of appropriate response and failure to report the incident as required by policy resulted in the facility not ensuring the resident was free from verbal abuse and intimidation.
Failure to Timely Report Alleged Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident and a staff member to the State Agency and local law enforcement within the required 24-hour timeframe. The incident involved a resident with diagnoses including osteomyelitis, type 2 diabetes mellitus with skin complications, traumatic amputation of the right great toe, hyperlipidemia, bipolar disorder, and hypertension, who was cognitively intact. The resident requested a grilled cheese sandwich from a dietary aide, who responded with profane language and refused the request. Multiple staff members, including a nurse and the dietary manager, were made aware of the incident, and statements were collected from those involved and witnesses. Despite the facility's policy requiring immediate reporting of potential abuse, the administrator, who also served as the Abuse Coordinator, did not report the incident. The administrator was notified of the situation the night it occurred but considered it a customer service issue rather than verbal abuse, despite staff indicating otherwise. The dietary manager, who believed the incident constituted verbal abuse, was instructed by the administrator not to terminate the staff member for abuse to avoid mandatory reporting to public health authorities. The dietary manager ultimately resigned due to concerns about the handling of the situation. A review of facility records revealed that no report of the incident was made to the State Agency or law enforcement, and the required documentation was not present. The facility's abuse prevention policy outlines clear steps for reporting and investigating allegations of abuse, including immediate notification of authorities and documentation of actions taken. These procedures were not followed in this case, resulting in a failure to comply with regulatory requirements for reporting suspected abuse.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of staff-to-resident verbal abuse involving a resident with multiple medical conditions, including osteomyelitis, diabetes with skin complications, traumatic amputation, hyperlipidemia, bipolar disorder, and hypertension. The resident, who was cognitively intact, reported that a dietary staff member used profane language and refused to prepare a requested meal. Multiple staff statements corroborated the resident's account, indicating that the staff member was insubordinate, used inappropriate language, and refused to fulfill meal requests. The incident was promptly reported to the dietary manager and administrator, and the staff member was sent home and subsequently terminated for various offenses, including inappropriate conduct toward a resident and sleeping on duty. Despite the immediate actions taken by the dietary manager, the administrator, who was also the facility's abuse coordinator, did not initiate or complete a formal investigation into the incident as required by the facility's Abuse Prevention Program Policy. The administrator acknowledged awareness of the incident but classified it as a customer service issue rather than potential verbal abuse, and did not review all relevant documentation or conduct interviews beyond reviewing employee discipline paperwork. There was no documentation of the incident in the facility's reportable abuse incidents, and the required investigation steps outlined in facility policy—such as interviewing all involved parties and reviewing the circumstances—were not followed. The lack of a thorough investigation was further highlighted by the dietary manager's resignation, citing an inability to address the abuse situation appropriately due to administrative direction. The administrator's decision not to classify the incident as abuse and not to report it to the state agency resulted in the facility failing to meet its obligation to promptly and aggressively investigate all reports and allegations of abuse, as outlined in its own policy. This deficiency was identified through interviews, record reviews, and the absence of required documentation and reporting.
Failure to Provide Timely Incontinence Care and Repositioning for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care and repositioning services for three dependent residents who required assistance with activities of daily living (ADLs). Observations and interviews revealed that these residents, all of whom had significant cognitive and physical impairments, were not repositioned or provided incontinence care as required. For example, two residents were observed sitting in the dining room for approximately three hours without being repositioned or toileted, despite being dependent on staff for these needs. One resident, who was always incontinent of bowel and bladder and dependent for all ADLs, was observed in her wheelchair throughout the day without being changed or repositioned from the time she was gotten up for breakfast until late afternoon. Both the resident and the CNAs confirmed that she had not been changed or laid down during this period. Staff interviews indicated that delays in meal service frequently disrupted the regular schedule for turning, repositioning, and providing incontinence care, resulting in residents not receiving care every two hours as expected. Multiple CNAs and supervisory staff acknowledged that the affected residents were incontinent and required assistance with turning and repositioning. Staff also stated that late meal service often interfered with their ability to maintain the required care schedule. The facility's policy required repositioning and skin care every two hours, but this standard was not met for the residents in question. The facility did not provide a policy specifically regarding ADL care to the surveyors.
Failure to Implement Pressure Ulcer Prevention Interventions for High-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including chronic obstructive pulmonary disease, malnutrition, osteoporosis, cancer, and cognitive impairment, was identified as being at risk for pressure ulcer development. The resident was dependent on staff for all mobility and transfers and was incontinent of bowel and bladder. Despite these risk factors, the care plan did not include specific interventions for the use of pressure-relieving devices for the resident's chair or bed, even though the Minimum Data Set indicated such devices should be used. Braden assessments initially rated the resident as low risk, but this was later determined to be inaccurate given the resident's condition. During multiple observations, the resident was seen in a reclining wheelchair without a pressure-relieving cushion and was not repositioned for at least three consecutive hours, contrary to facility policy requiring repositioning every two hours. Staff interviews confirmed that pressure-relieving cushions were expected for all residents at risk, but the resident had not received one. Additionally, the resident was found to have red, blanchable areas on the coccyx and ankles, which progressed to a non-blanchable area with skin peeling over the coccyx, indicating the development of a pressure injury. Documentation review revealed that no new physician orders or treatments were in place for the coccyx area at the time of the deficiency, and the resident was still on a standard mattress rather than a pressure-reducing mattress. Staff acknowledged that the Braden assessment had been completed incorrectly and that the resident should have been classified as higher risk. The facility's policy required special mattresses and chair cushions for high-risk residents, but these interventions were not implemented prior to the development of the pressure injury.
Failure to Prevent Elopement of At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent an elopement for a resident identified as being at risk for wandering and elopement. The resident had a history of intellectual disabilities, paranoid schizophrenia, anxiety, and difficulty walking. The resident's care plan documented impaired safety awareness and a pattern of sitting by exit doors, with interventions to identify and address wandering. Despite these risk factors, the resident was not wearing an electronic monitoring device at the time of the incident, as he had not previously attempted to leave the facility. On the day of the incident, staff observed the resident exhibiting increased restlessness and exit-seeking behavior, including packing belongings and expressing a desire to leave. The resident was last seen eating lunch in the dining room, after which staff noticed he was missing. A search of the facility was conducted, and when the resident could not be located, the police and the resident's power of attorney were notified. The resident was later found safe at a family member's house, having left the facility on his own without staff knowledge or intervention. Interviews with staff and family confirmed that the resident had never previously attempted to elope, although he had a pattern of preparing to leave and waiting for family. Staff reported that the wander guard system was operational, but the resident was not wearing a device. The incident revealed that the facility's supervision and monitoring were insufficient to prevent the resident's unsupervised exit, despite documented risk factors and recent changes in the resident's behavior.
Rodent Contamination Found in Food Storage Area
Penalty
Summary
Surveyors observed that the facility failed to maintain the dry food storage area free from contamination by rodents and rodent droppings. During inspection, a pile of small pieces of plaster or wood and a hole above it were found in the corner of the dry storage room, with several mouse droppings noted on shelves containing food items around the room's perimeter. The Administrator confirmed that although a pest control company had previously covered three holes believed to be entry points for mice, she was unaware that mice had chewed through one of the repairs. The Regional Clinical Director stated that the facility did not have a specific dry storage area policy. The facility's pest control policy indicated an ongoing program to keep the building free of insects and rodents. At the time of the survey, 94 residents were residing in the facility.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in multiple residents reporting sightings of mice in their rooms and evidence of rodent activity throughout the building. Several residents, all of whom were cognitively intact or had only moderate cognitive impairment, described seeing mice in their rooms, finding mouse droppings in personal belongings, and, in one case, having a mouse on a resident's bed. Observations confirmed the presence of mouse droppings in resident rooms, open food items accessible to pests, and mouse bait boxes in use. Staff interviews revealed that sightings of mice were common knowledge, and one CNA stated she did not report a mouse sighting because mice were present throughout the building. Further inspection of the facility revealed unsanitary conditions conducive to pest infestation, including food debris on floors, open snacks in resident rooms, and a dry storage area in the kitchen with mouse droppings and a hole chewed through the wall. The maintenance room door was found propped open to the outside, providing potential access for rodents. The pest control company had informed the facility that bait boxes would not be effective as long as food sources remained available to the mice. Facility records confirmed an ongoing pest control program, but the presence of rodents and evidence of their activity indicated the program was not effective in preventing or eliminating the infestation.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The deficiency was identified based on the facility's failure to provide necessary pain management interventions for a resident in need.
Failure to Provide Accessible and Sufficient Hydration for Residents
Penalty
Summary
The facility failed to ensure that residents had access to water in their rooms, as required to maintain adequate hydration. Observations and interviews revealed that four residents did not have water readily available or accessible. One resident with cerebral palsy, acute kidney failure, diabetes, and hypertension was found unable to reach his water pitcher, which was placed out of reach on a table at the foot of his bed. Another resident with heart failure and cognitive communication deficit reported that his water was not refreshed for several days, was hot, and lacked ice, requiring him to get his own ice. A third resident with cerebral infarction and moderate cognitive deficit stated that he was not offered ice water and typically had to get it himself, sometimes finding no ice available. The fourth resident, who had a right femur fracture and was cognitively intact, reported that her water pitcher was only filled upon request and that she usually poured water from meal cups into her pitcher. Staff interviews confirmed that there were complaints from residents about not receiving ice or water, and that the responsibility for passing water was not consistently fulfilled. The Director of Nurses stated that staff should be passing ice water at the beginning of each shift, with meals, and as needed. However, the facility was unable to provide a policy regarding ensuring water availability in resident rooms, further contributing to the deficiency.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The absence of a working call system in these locations was directly noted during the survey, but no additional details about specific residents, their medical history, or their condition at the time were provided in the report.
Failure to Ensure Call Light Accessibility During Call System Outage
Penalty
Summary
A deficiency was identified when a resident with a right femur fracture, muscle weakness, and difficulty walking was found without access to a functioning call light system. The resident, who was cognitively intact and required assistance with transfers, was observed sitting on the edge of her bed, unable to reach a bell placed on the opposite side of the bed. She reported having to yell for assistance, with no staff responding until the surveyor intervened. The resident also stated that there was no working call system in her room or bathroom and recounted an incident where she was left on the commode for 30-45 minutes after calling for help. Staff interviews confirmed that the call system had been down for several days, and residents were provided with bells as an alternative means to request assistance. Staff reported that they attempted to ensure residents had their bells with them, including during bathroom visits, and conducted 15-minute checks. However, it was acknowledged that the bells were not always within reach and were less effective than the standard call system, making it more difficult to identify which resident needed help. The administrator confirmed the call system outage and stated that residents were expected to take the bells with them.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Protect and Promote Resident Rights for Incarcerated Individual
Penalty
Summary
A resident was admitted to the facility for a short-term stay to receive intravenous antibiotics following a recent hospital stay, with diagnoses including sepsis and the presence of a cardiac pacemaker. The resident was alert, oriented, and largely independent in self-care activities. The admission contract and care plan outlined the resident's rights, including dignity, self-determination, communication, and the ability to retain personal property. However, the care plan did not address the use of physical restraints, preferred activities, personal property, or communication rights. Upon admission, the resident, who was an inmate of the federal prison system, was placed under constant supervision by two armed federal prison guards and was handcuffed to the bed. The resident was not allowed to leave the room, participate in facility activities, have visitors, use the telephone, or possess personal property or clothing. The facility administrator stated that these restrictions were imposed by the federal prison system, but there was no contract or policy in place between the facility and the federal prison system regarding the care of inmates. The resident's admission contract did not include any restrictions on rights due to incarceration. Staff interviews and direct observation confirmed that the resident remained confined to the room, was not permitted to use the call light, and had no personal belongings. The federal prison captain confirmed that these restrictions were based on prison protocols, but could not provide documentation of these protocols. The facility did not have policies or protocols for admitting inmates for medical care, and previous inmate admissions had not involved such restrictive measures. The lack of a care plan addressing these restrictions and the absence of facility policies contributed to the failure to protect and promote the resident's rights.
Failure to Prevent and Treat Heel Ulcers Resulting in Sepsis and Death
Penalty
Summary
The facility failed to prevent the development of unstageable ulcers, properly identify and assess newly developed ulcers, consistently implement interventions to promote healing, and follow physician orders for wound care for a resident with multiple comorbidities, including Parkinson's disease, diabetes, and peripheral vascular disease. The resident was admitted without heel ulcers, but later developed full-thickness arterial wounds on both heels. Documentation shows that the right heel ulcer was first identified after the resident's daughter noticed blood on the sock, but there was no physician order for treatment of this wound for approximately two weeks. The left heel ulcer was not documented or assessed until it was identified by the wound specialist, and there was no record of when it first developed or how it was initially managed. Throughout the resident's stay, there were significant lapses in wound assessment and documentation. Weekly skin records and progress notes failed to consistently document the status of the heel ulcers, and there were missed assessments on several dates. The care plan did not include specific interventions such as heel offloading or heel protection, despite the resident's high risk for skin breakdown. Orders for heel protectors were not implemented until late in the course of the resident's decline. Additionally, wound care interventions, such as debridement and dressing changes, were inconsistently documented, and there was no evidence that wound cultures were obtained or that antibiotics were started in response to signs of infection, despite care goals indicating the presence of odor and infected tissue. The resident's condition deteriorated, with increasing lethargy, fever, and hypotension, eventually leading to hospitalization for sepsis, gangrene, and necrosis of the bone and surrounding tissue in both heels. Hospital records confirmed the presence of large, necrotic, foul-smelling ulcers with exposed bone and tendon, requiring surgical debridement. The resident was subsequently placed on hospice and died from cardiorespiratory failure due to septic shock. The survey identified Immediate Jeopardy due to the facility's failure to provide appropriate wound care and follow physician orders, resulting in severe harm and death.
Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple chronic pain-related diagnoses, including polyneuropathy, osteoarthritis, myalgia, lumbago with sciatica, and osteoporosis. The resident was cognitively intact and consistently reported daily severe pain that interfered with mobility and participation in daily activities. Despite having orders for acetaminophen, ibuprofen, gabapentin, and a lidocaine patch, the resident continued to experience significant pain, which was not adequately controlled by the prescribed medications. The resident reported that the pain was never as low as a zero or three on the pain scale, and at times rated it above ten, even after receiving pain medication. The resident also expressed that the gabapentin made her tired without providing much relief, and she was unable to use her walker due to the pain, resulting in increased wheelchair use and decreased activity. Pain assessments and documentation were inconsistent and incomplete. The Medication Administration Record (MAR) showed that pain levels were not documented for most days, and when documented, did not reflect the resident's reported pain experience. Staff interviews revealed that pain assessments were often conducted as casual conversations rather than thorough evaluations, and sometimes were completed by referencing the resident's chart rather than direct interaction. The Care Plan Coordinator admitted to not conducting in-depth pain assessments and not always asking the resident the required questions. Nursing staff acknowledged the resident's ongoing pain complaints but expressed a lack of options for further pain management, with one nurse stating there was nothing more that could be done and another unaware of the resident's diagnoses. The facility's pain management policy required prompt and accurate assessment and management of pain, including consistent documentation and monitoring as the fifth vital sign. However, the facility did not follow these procedures, resulting in the resident experiencing uncontrolled severe pain, decreased mobility, and reduced participation in daily activities. The physician was unaware that pain assessments were not being completed as required and expected staff to document pain consistently. The failure to adhere to the facility's pain management policy and to respond appropriately to the resident's pain complaints led to the identified deficiency.
Failure to Provide Adequate Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple resident and staff interviews, record reviews, and direct observations. Several residents, all of whom were cognitively intact and dependent on staff for activities of daily living such as toileting, transferring, and personal hygiene, reported excessive wait times for call light responses, particularly on weekends. One resident described waiting over an hour for assistance on a Sunday, while another reported a 30-minute wait after activating the bathroom call light, followed by an additional 15-minute delay before being helped off the toilet. These delays were corroborated by staff interviews and direct observation of a resident's call light being ignored for an extended period while staff walked past the room. Staff interviews consistently indicated that staffing levels, especially on weekends and certain shifts, were insufficient to meet resident needs in a timely manner. CNAs and nurses reported working alone on halls with up to 30 residents, making it difficult to answer call lights promptly, complete required care tasks, and provide timely assistance with activities such as getting residents out of bed, passing supper trays, and performing two-person transfers. Staff described situations where they had to pull nurses away from medication administration to assist with resident care due to the lack of available CNAs. Multiple staff members stated that with only one CNA per hall, it was not feasible to meet all resident needs promptly, particularly during busy periods such as meal times and when families were visiting. Review of facility staffing schedules confirmed that on several occasions, including weekends and holidays, the number of CNAs and nurses scheduled was below the facility's stated expectations and insufficient to cover the resident population. The Director of Nursing acknowledged that the facility did not have a call light policy but expected call lights to be answered within 10 to 15 minutes, and agreed that 30-minute wait times were not timely. The facility's own assessment tool stated that staffing should be based on resident needs and acuity, but the documented schedules and staff accounts demonstrated that this standard was not consistently met, resulting in unmet resident needs and delayed care.
Deficiencies in Food Storage, Handling, and Sanitation
Penalty
Summary
Surveyors observed multiple failures in food storage, handling, and sanitation within the facility's dietary services. A large accumulation of ice was found on the freezer floor and on two boxes of food, with some individual ice creams having fallen out of their box onto the floor due to the ice. The Dietary Manager confirmed there was a leak in the freezer that worsened during storms and stated that short staffing and additional duties prevented timely cleanup. Additionally, a Dietary Aide was seen transferring glasses by the rim with gloved hands after touching various surfaces, including a milk carton, her shirt, the drink cart, health shakes, the ice scoop, and her face. Another Dietary Aide wiped a counter with a cloth from a sanitizer bucket and then began preparing sandwiches; the sanitizer solution was found to be less than 25 parts per million chlorine, and the aide was unaware of the required sanitizer level. These deficiencies had the potential to affect all 96 residents in the facility. No specific residents or their medical histories were mentioned in the report, but the documented census indicated 96 residents were present at the time of the survey.
Failure to Provide Dietician-Approved Food Portions and Consistent Meal Service
Penalty
Summary
The facility failed to provide food portions as directed by the dietary spreadsheet approved by the registered dietician for four residents out of a sample of seventeen reviewed for dining. Specifically, residents with complex medical histories, including diabetes, chronic kidney disease, dementia, malnutrition, and other conditions, were served ham portions that were less than the required 3 ounces specified on the dietary spreadsheet. The dietary manager weighed the ham and found it to be just under 2.75 ounces, and this amount was served to multiple residents. Staff confirmed that the correct portion should have been 3 ounces and acknowledged that the facility had equipment capable of slicing the ham to the appropriate size, but this was not done. Additionally, facility documentation and resident council forms indicated ongoing concerns about food service, including inconsistent portion sizes, meal tickets not being read properly, and residents receiving items they did not like. These issues were noted as recurring, particularly during dinner and weekends, and there were reports of insufficient food to complete meal service. These findings were based on interviews, observations, and record reviews conducted by surveyors.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a palatable and safe temperature for four residents during meal service. On the day of the survey, the dietary manager measured the temperature of honey glazed ham before serving and found it to be 90 degrees Fahrenheit in three different locations, which is below the facility's policy requirement of 136 degrees or above for hot foods. Despite this, the ham was served to residents without any attempt to raise its temperature. Later, a tray refused by a resident was tested and the ham was found to be 83 degrees Fahrenheit. Multiple residents who received the ham during lunch expressed that the food was not hot, with comments indicating it was barely warm or not even warm. All affected residents were alert and oriented at the time of the meal. The facility's policy clearly states that hot foods must be held at 136 degrees or above until served, but this procedure was not followed, resulting in the deficiency.
Failure to Provide Food in Physician-Ordered Texture
Penalty
Summary
The facility failed to provide food in the appropriate texture as ordered by physicians for four residents who required mechanical soft diets. Despite having active orders and care plans specifying the need for mechanical soft or chopped food textures, these residents were served pieces of cauliflower that exceeded the recommended size for their dietary needs. In one instance, a resident also did not receive a prescribed PB&J sandwich with their meal. These actions were observed during meal service and were not in accordance with the dietary orders documented in the residents' records. The residents affected had significant medical histories, including conditions such as hemiplegia, dementia, Parkinson's disease, chronic obstructive pulmonary disease, and dysphagia. Their care plans and physician orders clearly indicated the need for modified diets, such as mechanical soft textures and specific food items to be provided at certain meals. The facility's own diet spreadsheet and policy required that food be prepared and served according to these orders, and that a tray identification system be used to ensure accuracy. Additional documentation from resident council forms indicated ongoing concerns about meal service, including reports that meal tickets were not being read properly, residents were receiving items they did not like, and portion sizes were inconsistent. These issues suggest that the facility's processes for preparing and serving meals according to individual dietary needs were not consistently followed, resulting in the observed deficiencies.
Failure to Timely Respond to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to answer call lights for residents needing assistance in a timely manner, impacting the dignity and care of three residents who were dependent on staff for toileting, personal hygiene, bed mobility, and transferring. One resident reported waiting over an hour for call lights to be answered on multiple occasions, particularly on weekends, and another described waiting 30 minutes after activating the bathroom call light, followed by an additional 15-minute wait before being assisted off the toilet. Observations confirmed that a resident's call light remained activated for over 20 minutes while multiple staff members walked past without responding. Residents expressed frustration with the long wait times and attributed the delays to insufficient staffing. Staff interviews corroborated these concerns, with a CNA and a registered nurse both stating that call lights were not answered promptly when staffing levels were low, particularly when only one CNA was assigned to a hallway with 30 residents. The Director of Nursing acknowledged the absence of a call light policy and stated that a 10 to 15-minute response time would be considered timely, but 30-minute waits were not acceptable. The lack of a formal policy and inadequate staffing contributed to the failure to meet residents' needs for timely assistance, as documented through resident interviews, staff statements, and direct observation.
Failure to Formulate or Offer Advance Directives Upon Admission
Penalty
Summary
The facility failed to formulate or offer to formulate an advance directive for two residents upon admission, as required by policy. For one resident with severe cognitive impairment and multiple diagnoses, including dementia and metabolic encephalopathy, the admission record left the advanced directives section blank. Multiple staff members, including a registered nurse, social service assistant, and the DON, were unable to locate any documentation of an advance directive, POLST form, or code status in the resident's electronic health record or care plan. The absence of this documentation meant that staff would not know what type of care to provide in an emergency. A POLST form was later produced, but it was signed on the day of the survey, and the signature date was initially incorrect and had to be corrected in front of surveyors. For a second resident, who was mostly cognitively intact and had several chronic conditions, the care plan indicated full code status, but there was no copy of an advance directive or POLST form in the electronic health record at the time of review. The POLST form was only signed and dated after the surveyor's inquiry. Facility policy requires that residents be provided with information about advance directives upon admission, and that staff document the offer to assist and the resident's decision. In both cases, these steps were not completed as required.
Failure to Timely Report Peer-to-Peer Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of peer-to-peer abuse to the Administrator, as required by policy. One resident with severe cognitive impairment reported that another resident, who also has a history of adverse behaviors and severe cognitive deficits, entered her room and hit her. Another resident, who is cognitively intact, corroborated that the alleged aggressor entered the room and was physically aggressive. Staff interviews confirmed that the resident in question is known to be physically combative and has a pattern of wandering into other residents' rooms, sometimes becoming aggressive. Despite these reports and observations, there was no documentation in the residents' progress notes or in the facility's abuse/neglect allegation records regarding this specific incident of peer-to-peer aggression. Staff members, including CNAs and an LPN, were aware of the incident, with one LPN responding to a call for help and finding the alleged aggressor in the room. The LPN and a CNA both documented that the resident who was allegedly hit denied being struck but wanted the other resident removed from her bed. However, the incident was not reported to the Administrator until the surveyor brought it to their attention. The facility's Abuse Prevention Training Program requires that all allegations of potential abuse, neglect, or mistreatment be reported immediately to the Administrator. In this case, the failure to report the incident in a timely manner resulted in a delay in initiating an investigation and notifying the appropriate authorities, as required by facility policy and regulatory standards.
Failure to Provide Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives at the time of transfer to the hospital for two residents who were hospitalized. According to the facility's own bed hold policy, a copy of this policy is required to be given to residents at admission and each time they are transferred from the facility. For both residents reviewed, there was no documentation in the electronic health record or nurse's progress notes that the bed hold policy was provided to either the residents or their representatives during their respective hospitalizations. One resident had diagnoses including chronic obstructive pulmonary disease, dementia, and required moderate assistance with daily activities. This resident was able to communicate but was cognitively confused. The other resident had diagnoses such as metabolic encephalopathy, chronic obstructive pulmonary disease, and was dependent for all functional abilities, unable to participate in a mental status interview. In both cases, despite their significant medical needs and vulnerability, there was no evidence that the required bed hold policy notification was given at the time of their transfer to the hospital.
Failure to Maintain Current PASSR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a current Preadmission Screening and Resident Review (PASSR) Level 2 screening was in place for one resident with multiple mental health diagnoses, including schizoaffective disorder, agoraphobia with panic disorder, insomnia, major depressive disorder, and anxiety disorder. The resident's medical record showed a previous PASSR evaluation that granted short-term approval without specialized services, with an end date that had already passed. No updated PASSR screening was documented after the expiration of the previous approval. The resident's care plan and assessments indicated ongoing mental health needs, but the required PASSR process was not completed in a timely manner due to oversight, as the staff member responsible for requesting the screening was new and had not yet submitted the request.
Failure to Assist Residents with Meal Setup and Dietary Needs
Penalty
Summary
The facility failed to provide necessary assistance with meals and dietary needs for three residents who required help with activities of daily living, specifically during mealtimes. One resident with severe cognitive impairment, hemiplegia, rheumatoid arthritis, and other chronic conditions was observed unable to remove lids from her food containers or open condiment packets. Despite her attempts and visible struggle, she did not receive timely assistance until prompted by an inquiry to a staff member. Dietary staff later confirmed that due to her hand contractures, staff should have been removing lids and opening condiments when delivering her meals. Another resident with moderate cognitive impairment, multiple chronic illnesses, and documented difficulty chewing was observed struggling to remove lids from her dessert and ice cream. She was unable to open these items and eventually gave up, requesting assistance only after several minutes. Dietary staff confirmed that for residents assessed as needing tray setup, staff are expected to remove lids, open cartons, and ensure food is ready to eat, which was not done in this instance. A third resident, also with moderate cognitive impairment and a history of fractures, malnutrition, and muscle weakness, was observed sitting in front of her meal without having taken any bites. She was not encouraged or assisted by staff who walked by, and only began eating after the administrator personally intervened and provided assistance. The facility's policy requires that residents receive meal assistance according to their individual needs, which was not followed in these cases.
Failure to Remove Discontinued Medications and Prevent Improper Storage
Penalty
Summary
A deficiency occurred when a resident was found storing discontinued medications at their bedside, which had not been properly removed by nursing staff. The resident, who was cognitively intact and had diagnoses including alcohol dependence with withdrawal, chronic obstructive pulmonary edema, hypertension, anxiety disorder, and major depressive disorder, reported that a nurse had attempted to administer a discontinued medication. The resident identified the error, did not take the medication, but kept it in a medication cup on the bedside table. The resident also had another pill in the cup that had been discontinued months prior. There was no care plan or intervention documented that allowed the resident to self-administer medications. Interviews with the LPN involved revealed that she had mistakenly given the resident a discontinued medication, and was unaware of the presence of the other discontinued pill. The DON confirmed that one of the pills had been discontinued recently and the other several months ago. Facility policy requires that only licensed staff administer medications and that residents may only self-administer if specifically authorized by the care team and physician, which was not the case for this resident. The failure to remove discontinued medications and prevent their storage at the bedside, as well as the lack of proper documentation for self-administration, led to the deficiency.
Failure to Provide Correct and Timely Meals to Resident
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including metabolic encephalopathy, vascular dementia, dysphagia, and muscle weakness, did not receive a meal as required. The resident, who had moderate cognitive impairment, was observed on one occasion expressing hunger and stating that she had been forgotten for a meal the previous night. Additionally, there was a documented lack of food intake for dinner on a specific date. During another observation, the resident was found with a lunch tray intended for another resident, and staff only realized the error after it was pointed out by a surveyor. The correct lunch tray was then delivered, but the incident resulted in another resident not receiving their meal in a timely manner. Facility records and resident council forms further documented ongoing concerns about meal service, including dietary tickets not being read properly, residents receiving incorrect or disliked food items, and inconsistent portion sizes, particularly at dinner. These issues were noted as recurring and unresolved, contributing to the failure to provide nourishing, palatable, and well-balanced meals that meet residents' dietary needs.
Failure to Follow Resident Dietary Preferences and Restrictions
Penalty
Summary
The facility failed to accommodate the dietary preferences and restrictions of three residents as observed through meal service and review of dietary records. One resident with multiple diagnoses, including diabetes and dementia, had a physician order for a no added salt diet and was specifically noted to avoid apple juice. Despite this, the resident received apple juice on her breakfast tray and expressed her dislike for it. Another resident with chronic kidney disease and other conditions was served cauliflower, which was listed as an allergy on her dietary card, despite her repeated statements that she does not like it. The resident also commented on the temperature and quality of the food, indicating ongoing dissatisfaction. A third resident with dementia and psychiatric diagnoses received drinks with ice, contrary to her dietary card instructions specifying no ice. Additionally, facility documentation from resident council meetings indicated ongoing concerns about dietary tickets not being read properly, resulting in residents receiving food items they do not like or cannot have. The facility's policy requires identification of food preferences within 72 hours of admission, but these incidents demonstrate a failure to consistently follow documented dietary preferences and restrictions for multiple residents.
Failure to Provide Adaptive Eating Equipment as Ordered
Penalty
Summary
The facility failed to provide adaptive eating equipment as ordered for two residents with specific needs. One resident, with diagnoses including chronic kidney disease, dementia, failure to thrive, anemia, Alzheimer's disease, and weakness, had a physician's order and care plan indicating the use of built-up utensils. Despite this, the resident received regular utensils at both lunch and breakfast on multiple occasions, and reported not always receiving the larger silverware as required. Another resident, diagnosed with Parkinson's disease, femur fracture, irritable bowel syndrome, low back pain, muscle weakness, major depressive disorder, anxiety disorder, and weakness, had an active order for weighted utensils. This resident also received regular utensils instead of the prescribed adaptive equipment at several meals and stated that she does not always get the bigger silverware, though her sister wants her to use them. Dietary staff confirmed that kitchen staff are responsible for reading meal tickets and ensuring adaptive equipment is provided. Facility documentation also noted concerns about meal tickets being read incorrectly, resulting in residents not receiving appropriate items.
Failure to Prevent Resident Burns from Hot Liquids
Penalty
Summary
The facility failed to adjust the type and frequency of interventions and the needed level of supervision for a resident with a history of self-inflicted burns with hot liquids. This deficiency resulted in the resident spilling hot water onto his groin, sustaining second-degree burns to nine percent of his body, causing pain and the need for increased pain medication, and requiring placement of an indwelling catheter to prevent urine from irritating the wounds. The resident, who has diagnoses including spinal stenosis with fusion of the lumbar spine, schizoaffective disorder, and diabetes type 2, was dependent on staff for transfers and required assistance for eating. The resident's care plan documented that he displayed adverse behaviors and had been educated to let staff get him hot water to prevent burns, but he continued to be non-compliant. On the day of the incident, the resident asked a Certified Nursing Assistant to heat water for him, which was returned in a pitcher. While attempting to remove the lid, the hot water spilled, causing burns. The resident had a history of similar incidents, and despite repeated education, he continued to handle hot liquids unsafely. The facility's policy required a systems approach to safety, adjusting interventions based on identified hazards and resident needs, which was not adequately implemented in this case. Interviews with staff revealed a lack of clarity about who provided the hot water and indicated that staff re-education was insufficient. The Assistant Director of Nurses and the Regional Nurse/Director of Nurses responded to the incident, but no staff member took responsibility for giving the resident the hot water. The facility's policy emphasized the need for resident supervision and adjusting interventions based on individual needs and environmental hazards, which was not effectively applied, leading to the resident's injury.
Medication Administration Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, identified as R1, who was admitted with diagnoses including a nondisplaced fracture of the lateral condyle of the right tibia, restless leg syndrome, and fibromyalgia. On the night of the incident, a registered nurse, V7, mistakenly administered medications intended for another resident, R2, to R1. The nurse did not use two identifiers to confirm the resident's identity, leading to R1 receiving Tylenol and Benadryl instead of her prescribed medication, Ropinirole, for restless leg syndrome. The nurse, V7, admitted to having R2's Medication Administration Record open and mistakenly addressed R1 as R2, to which R1 responded affirmatively. After the error was realized, R1 attempted to spit out the medications. The nurse did not notify the physician about the unavailability of R1's prescribed medication, Ropinirole, which had not yet arrived from the pharmacy. The nurse did not consider the situation an emergency and did not take further action to obtain the medication from the emergency kit or notify the physician. The facility's policy requires the use of two identifiers when administering medications, such as checking identification bands or photographs and calling the resident by name. The Director of Nursing and the Administrator both acknowledged that the nurse should have used two identifiers and notified the physician about the unavailable medication. The incident highlights a lapse in following established protocols for medication administration and communication with the physician regarding medication availability.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident identified as R2, who was at high risk for falls due to multiple health conditions, including Parkinson's disease, repeated falls, and difficulty walking. R2's care plan included specific interventions such as placing fall mats at the bedside and ensuring the bed was in the lowest position. However, during observations on multiple occasions, it was noted that the fall mats were not in place, and the bed was not consistently in the lowest position, which contributed to R2 experiencing falls. R2 had a history of falls, with documented incidents where the resident was found on the floor, resulting in injuries such as a bleeding head wound and a skin tear. Despite these incidents, the facility staff, including CNAs and the Director of Nurses, were unaware of why the fall mats were not consistently in place. This lack of adherence to the care plan interventions and inadequate supervision led to the deficiency identified by the surveyors.
Failure to Provide Prescribed Dietary Supplements and Portions
Penalty
Summary
The facility failed to provide supplements and double portions as ordered for six residents, including a resident with severe cognitive impairment and multiple diagnoses such as dementia and anxiety disorder. This resident was observed not receiving the prescribed double portions and supplements during meals, despite having a care plan that included specific dietary interventions to address weight loss risk. Observations revealed that the resident's meal trays lacked the required double portions and supplements, such as ice cream and fortified pudding, which were part of the dietary orders. Further investigation showed that during meal service, the dietary manager did not ensure that residents with orders for double portions received them. The dietary staff failed to communicate effectively with the cooks, resulting in the omission of special dietary needs from the meal trays. The registered dietitian and the director of nursing both expressed expectations that dietary orders should be followed, but the dietary manager admitted that no double portions were provided during the observed meal service. This lack of adherence to dietary orders was documented for multiple residents, indicating a systemic issue in the facility's dietary service.
Failure to Label Insulin with Open Dates
Penalty
Summary
The facility failed to properly label insulin with open dates for four residents, leading to a deficiency in medication labeling and storage. During an observation, it was found that insulin vials for residents with various medical conditions, including type 2 diabetes mellitus, were open without any indication of the opening date. This included insulin lispro and insulin glargine for residents with chronic conditions such as chronic obstructive pulmonary disease, peripheral vascular disease, and chronic respiratory failure. The lack of labeling was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that all insulins should be dated when opened and discarded after 30 days if the open date is not recorded. The Director of Nursing (DON) was also interviewed and stated that staff were expected to label all insulin with an open date, although he was unsure about the specific facility policy regarding insulin labeling and storage. The facility's policy from December 2018 indicated that staff should ensure multi-dose vials are stored according to the manufacturer's suggested conditions. Additionally, an undated Insulin Reference Chart from the facility documented that insulin lispro and insulin glargine expire 28 days after opening. This oversight in labeling insulin vials with open dates led to a deficiency in the facility's medication management practices.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to provide pureed diets according to its established recipes for 13 residents out of a sample of 20 reviewed for dietary needs. During an observation, the Dietary Manager (V6) was seen preparing pureed pasta salad and cheeseburgers without following the facility's recipes. Specifically, V6 added unmeasured amounts of ice water and a thickening agent to the pasta salad and used water and brown gravy instead of the specified beef broth for the cheeseburgers. These actions were contrary to the facility's recipes, which required specific liquids other than water to achieve the correct consistency. The Registered Dietitian (V12) confirmed that dietary staff were expected to adhere to the recipes when preparing mechanically altered foods. The facility's policy and recipes clearly outlined the procedures for preparing pureed diets, including the use of specific liquids to achieve the desired consistency. Despite these guidelines, the dietary staff did not follow the recipes, resulting in a failure to meet the nutritional needs of the residents who required pureed diets.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to adhere to the physician's orders for the treatment of scalp and facial wounds for a resident diagnosed with Parkinson's Disease, Adult Failure to Thrive, and Type 2 Diabetes. The resident's treatment plan included the application of an antimicrobial gel and calcium alginate gauze with a bordered dressing to the left face and scalp wounds daily. However, the Treatment Administration Record for July 2024 showed that the treatments were not administered on three specific dates, indicating a lapse in the prescribed care. During an observation, the resident was found to have dressings on the scalp and face that were not changed as frequently as ordered, and the resident was unsure of the dressing change schedule. The Wound Care Physician confirmed that the treatments were intended to be performed daily to prevent secondary infection, but was unaware of the inconsistency in care. The Director of Nursing also acknowledged that the wound care was supposed to be conducted daily during the night shift but was unaware of the lapses in treatment.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to develop and implement appropriate fall interventions for a resident (R2) who had a history of falls and was at risk due to conditions such as CVA, TIA, and gait/balance problems. Despite being educated to use a walker, R2 refused to use it, and the facility did not ensure she had one available. On 3/28/24, R2 fell while getting off a transit bus, resulting in a left patellar fracture. The facility's staff did not perform a full body assessment or notify the physician immediately after the incident, and R2 was not sent to the ER until the following day when her pain worsened. R2's care plan included interventions to educate her to use a walker at all times and on outings, but these were ineffective as R2 consistently refused to use the walker. The facility lost track of R2's walker, and it was possibly being used by another resident. Therapy services were not involved in assessing R2 for a walker until after the fall on 3/28/24. The facility's failure to ensure R2 had and used a walker, and to perform a timely and thorough assessment after the fall, contributed to the deficiency. Interviews with staff revealed that R2 had a history of falls and was known to refuse using a walker. Despite this, the facility did not take additional measures to ensure her safety. The Director of Nurses and the Administrator acknowledged that R2 had a walker upon readmission, but it was not used or tracked properly. The facility's fall management policy was not effectively implemented, leading to R2's repeated falls and subsequent injury.
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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