Jerseyville Nsg & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jerseyville, Illinois.
- Location
- 1001 South State Street, Jerseyville, Illinois 62052
- CMS Provider Number
- 145465
- Inspections on file
- 30
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Jerseyville Nsg & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls suffered fatal injuries after multiple falls, despite being identified as high fall risk and having interventions such as bed and chair alarms, fall mats, and a low bed in place. Staff interviews revealed that alarms were ineffective because the resident could turn them off, care plans were not consistently updated, and supervision was inadequate, leading to the resident being found on the floor with severe head injuries.
A resident with severe cognitive impairment and a history of wandering was able to elope after the facility failed to maintain door alarms at an adequate volume and did not ensure the exit gate latch was working. Staff and family reported the alarm could not be heard from key areas, and the resident was found outside the facility in the roadway. The gate to the fenced area was unlatched, allowing the resident to leave the premises.
A resident was able to exit the facility unsupervised due to a broken latch on the courtyard gate. The issue was discovered when the resident's family member and an LPN found the gate unsecured, and the resident was later located outside the facility by a member of the public. The DON confirmed the latch was broken and not in use, despite facility policy emphasizing resident safety.
A resident with dementia and a history of falls experienced increased pain after a fall, but staff did not promptly notify the physician or obtain further assessment, attributing the pain to the recent fall and continuing routine Tylenol. Despite repeated concerns from the resident's daughter and behavioral signs of pain, the issue was not escalated, and the resident was later diagnosed with a pelvic fracture that went untreated for eight days.
A resident with severe cognitive impairment and a history of falls did not have required bed and chair alarms in place as specified in the care plan and physician orders. This lapse resulted in an unwitnessed fall, during which the resident sustained a laceration. Staff interviews confirmed that alarms were not always used as required, and the facility did not provide a fall prevention policy.
A resident with severe cognitive impairment and a history of falls sustained a displaced fracture of the left femur due to the facility's failure to implement progressive fall interventions and conduct thorough investigations. Despite multiple falls and existing care plan interventions, the facility did not update the care plan with new measures to prevent further incidents, contrary to their fall policy.
The facility failed to obtain monthly weights for two residents, resulting in significant weight loss for one. A resident experienced a 15.6% weight loss over several months without proper monitoring, while another resident, on isolation for COVID-19, reported receiving cold meals and had no recent weight records. The facility's scale was broken for weeks, contributing to the lack of weight monitoring, despite policies requiring monthly checks.
The facility failed to ensure proper food storage and preparation, risking foodborne illness for all 48 residents. Observations included unlabeled and undated food items, dusty equipment, and improper storage of dented cans and opened containers. The facility's policies on food labeling and dating were not followed.
The facility failed to serve meals on time for four residents. Lunch, scheduled for 12:00 PM, was delayed, with meals being delivered between 1:19 PM and 1:25 PM. A CNA mentioned that meals are consistently late, and the administrator admitted that hall trays should not be delayed. The facility does not have a policy on meal service timeliness.
The facility failed to protect residents from abuse, as evidenced by two incidents involving a resident with severe cognitive impairment who hit two other residents. One incident occurred in a resident's room, where a cognitively intact resident was hit while in bed. The second incident took place in the dining room, where another resident was struck from behind. These actions violated the facility's abuse prevention policy.
The facility failed to investigate two separate allegations of abuse involving residents. In one case, a resident was found hitting another resident in their room, and in another, a resident hit a male resident in the dining room. Despite these incidents, the facility did not conduct the required abuse investigations as per their policy.
The facility failed to serve meals at a desirable temperature to two residents, one of whom was in isolation for COVID-19 and had a diagnosis of Moderate Protein Calorie Malnutrition. Food temperatures were found to be below acceptable levels, and residents reported dissatisfaction with the cold and unappetizing meals. The facility's administrator acknowledged issues with non-heated meal carts and ongoing efforts to address the problem.
The facility failed to ensure proper PPE use for two residents on Covid-19 isolation. A CNA was seen in a resident's room without a gown or gloves, and her mask was below her nose. Another resident was in the hallway with her mask below her chin. The facility's policy requires masks, gowns, and gloves for droplet precautions.
A resident, who is cognitively intact and uses a wheelchair, was unable to access the sink in their bathroom due to the layout, which included a toilet riser and grab bars obstructing access. This issue was not known to the DON until the survey, despite the resident's care plan indicating the need for environmental adaptations to support independence.
The facility did not post its licensed and unlicensed staffing information responsible for resident care, potentially affecting all 48 residents. The staffing was only posted in the employee break room, showing daily assignment sheets for CNAs and nurses, but lacking census or total hours worked per shift. The Regional Director of Clinical Operations acknowledged the oversight and mentioned plans to implement the required postings.
A resident with a gastrostomy tube was not properly monitored, leading to the tube being out for several days without staff awareness. Despite the resident's cognitive impairment and need for nutritional support, staff failed to assess the tube site regularly, resulting in the resident being sent to the hospital for possible reinsertion. An EMT noted the site was scabbed over, indicating neglect in care.
A facility failed to protect two residents with moderate cognitive impairment from sexual abuse. Despite being aware of inappropriate sexual behaviors between the residents, the facility did not implement adequate interventions to prevent further incidents. The residents' families were informed, but the facility did not assess the residents' capacity to consent or report the incidents to law enforcement, leading to a deficiency in resident protection.
A resident with moderate cognitive impairment eloped from a facility after another resident turned off the door alarm. The resident was found by a passerby hours later. The facility failed to provide adequate supervision and monitoring, despite the resident's known elopement risk. Staffing issues and the building layout further complicated supervision efforts.
Two residents with moderate cognitive impairment were involved in multiple incidents of inappropriate sexual behavior, but the facility failed to conduct thorough investigations or implement effective interventions to prevent further occurrences. Despite ongoing documentation of these incidents, the facility did not adhere to its Abuse Prevention Program Policy, which requires investigations for any allegations of abuse.
The facility failed to protect a resident's right to be free from sexual abuse by not effectively implementing its abuse policy. Two residents with dementia were in a relationship and found on two occasions with their pants and underwear off, despite staff being aware of their cognitive impairments and the need to keep them apart. The facility reported only one incident to the state agency and did not report to local law enforcement.
The facility failed to maintain adequate staffing levels, particularly during the night shift, with only two CNAs and one LPN on duty for 47 residents. This staffing shortage hindered the ability to provide necessary care and supervision, especially for residents at risk of falls. Staff were also required to perform laundry duties, further detracting from resident care. Despite financial constraints cited by management, the facility's assessment indicated a need for more nursing hours than were being provided.
The facility failed to report potential sexual abuse involving two residents with dementia to local law enforcement and the State Agency. Multiple incidents of inappropriate sexual behavior were documented, but the facility did not conduct thorough investigations or report them as required by their policy. Staff interviews confirmed awareness of the incidents, yet necessary reporting steps were not taken.
A resident with multiple diagnoses, including a UTI, experienced a delay in diagnosis and treatment due to a mix-up in lab orders. The facility failed to obtain the necessary culture and sensitivity report in a timely manner, leading to a serious infection. The resident's family expressed concerns about the facility's handling of the UTI, and the Director of Nursing acknowledged the error in lab orders.
Failure to Implement and Monitor Effective Fall Interventions
Penalty
Summary
A deficiency occurred when the facility failed to adequately evaluate, implement, and monitor the effectiveness of fall interventions for a resident with a history of falls, dementia with agitation, and severe cognitive impairment. The resident required substantial assistance for mobility, was assessed as a high fall risk on multiple occasions, and had a care plan that included interventions such as bed and chair alarms, fall mats, and keeping the bed in the lowest position. Despite these interventions, the resident experienced multiple falls, including a final incident resulting in severe injuries such as a depressed skull fracture, orbital and maxillary fractures, scalp laceration, and multiple brain hematomas. Staff interviews and record reviews revealed that the alarms intended to alert staff to the resident's movements were not effective, as the resident was able to turn them off. The care plan was not consistently updated to reflect the resident's changing needs or the ineffectiveness of certain interventions. For example, the use of a self-release belt was not documented as added to the care plan, and the bed and chair alarms, as well as the fall mat, were already in place prior to the final fall but were not effective in preventing the incident. Staff also reported that the resident was often left unsupervised in her room, and the visual indicator for high fall risk was not present outside her door at the time of the incident. Observations and interviews further indicated that the resident was found on the floor with significant injuries, and the alarms did not sound at the time of the fall. The facility did not have a formal alarm policy, and staff acknowledged that the interventions in place were not always appropriate or effective for the resident. The lack of effective monitoring and adaptation of interventions contributed to the resident's ability to attempt to get out of bed unassisted, ultimately resulting in a fatal fall.
Failure to Maintain Audible Door Alarms and Secure Exit Gate Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that its door alarms were sufficiently loud to be heard from areas away from the 200 hall exit door, and did not maintain the outside gate latch in working order. This deficiency was identified when a resident with severe cognitive impairment and a history of wandering was able to elope from the facility. Multiple staff and family members reported that the alarm on the 200-hall exit door could not be heard from the 100/300 hall nurse's station until they were much closer to the door, and even then, it was difficult to discern the type of alarm. At the time of the incident, there were no staff present at the 200 hall nurse's station, and the only therapy staff in the building was located at the front of the facility, away from the exit door in question. The resident involved had severe cognitive impairment, Alzheimer's Disease, and was ambulatory with supervision. On the day of the incident, the resident's son was visiting and, after briefly leaving the resident unattended, discovered she was missing. Staff and the son searched the facility and only became aware of the exit when they heard the alarm faintly while approaching the 200 hall. The resident was ultimately found outside the facility, in the roadway behind the building, by a bystander and family members. It was also noted that the gate to the fenced area outside the 200-hall door was not latched, allowing the resident to leave the premises. Interviews with staff and the resident's family confirmed that the alarm was not functioning at an adequate volume and that the gate latch was broken at the time of the incident. Staff also indicated that the alarm was not always audible from key locations within the facility, and the maintenance director acknowledged recent issues with the alarm system. The facility's elopement prevention policy required assessment and interventions for residents at risk, but the failure to maintain effective alarm audibility and secure exits directly contributed to the resident's elopement.
Failure to Maintain Courtyard Gate Latch Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that the latch on the courtyard gate was in proper working order, resulting in a resident being able to exit the facility without staff supervision. On the date of the incident, a resident's son and an LPN went outside to the fenced-in courtyard and discovered that the gate was neither locked nor latched. The resident was later found outside the facility by a member of the public, who contacted the facility to report the situation. The resident's son expressed concern about the safety of the facility, specifically citing the unsecured back fence as a reason for feeling unsafe and deciding to take his mother home. Interviews and record reviews confirmed that the latch to the gate off the 200-hall exit door was broken at the time of the incident. The Director of Nursing acknowledged that the latch was not functioning and stated that staff were told it was not required to be latched. Facility policy indicates a commitment to maintaining an environment free from accident hazards and prioritizing resident safety and supervision. At the time of the incident, there were 50 residents residing in the facility.
Failure to Timely Report and Treat Change in Condition After Fall
Penalty
Summary
A deficiency occurred when the facility failed to timely report and treat a change in condition for a resident with a complex medical history, including dementia, multiple fractures, and a high risk for falls. After a witnessed fall, the resident complained of pain, particularly when transferring, sitting, or standing, but the facility did not promptly notify the physician or obtain appropriate diagnostic testing for the new pain. Instead, staff attributed the pain to the recent fall and continued to administer routine Tylenol, while the resident's daughter repeatedly voiced concerns about the nature and persistence of the pain. Despite ongoing complaints and behavioral signs of pain, such as increased agitation and combativeness during transfers, the staff did not escalate the issue or seek further medical evaluation. The resident's daughter reported her concerns to both nurses and CNAs, but was told the pain was expected after a fall. The physician was not informed of the resident's increased pain or potential new injury, and the plan became to wait for an upcoming orthopedic appointment rather than pursue immediate assessment. The resident remained in pain for several days without a new evaluation or intervention. Eventually, at the orthopedic appointment, the resident was diagnosed with a right inferior pubic ramus fracture, which had gone unrecognized and untreated for eight days. Interviews with staff confirmed that the physician was not notified of the change in condition, and the Director of Nursing stated that she would have expected nurses to report such changes. The facility did not provide a change in condition policy for review.
Failure to Ensure Fall Prevention Interventions Were Consistently Implemented
Penalty
Summary
A deficiency occurred when the facility failed to ensure that fall prevention interventions were consistently in place for a resident with a significant history of falls and multiple risk factors. The resident, who was severely cognitively impaired and required substantial assistance with activities of daily living, had diagnoses including a displaced fracture of the left femur, emphysema, dementia, and tremors. The care plan specified the use of bed and chair alarms at all times, as well as other interventions such as scheduled toileting, non-skid socks, and increased supervision. Despite these documented interventions, the resident experienced an unwitnessed fall in her room after attempting to get out of bed without assistance. At the time of the fall, the bed alarm was not in place as required by the physician's order and care plan. Staff interviews confirmed that the alarm was not always in use, and the Director of Nursing acknowledged that the bed alarm was not in place at the time of the incident. The incident report and progress notes documented that the resident was found on the floor with a laceration to her finger and was incontinent at the time of the fall. The facility did not provide a fall prevention policy when requested. The failure to ensure that required fall prevention interventions were in place directly contributed to the resident's fall.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to provide progressive fall interventions and complete a fall investigation for a resident, resulting in a displaced fracture of the greater trochanter of the left femur. The resident, who was severely cognitively impaired and required substantial assistance for activities of daily living, had a history of falls and was at high risk for further incidents. Despite multiple falls occurring on specific dates, the care plan was not updated with new interventions to prevent future falls. The resident's care plan included various interventions such as staff assistance with toileting, use of non-skid socks, and encouragement to use a walker. However, after falls on several occasions, including one where the resident tripped over a walker, the facility did not document new interventions or adequately investigate the incidents. The resident experienced pain and bruising, and despite being sent to the hospital, no x-rays were initially performed to assess potential injuries. The facility's fall policy required assessment and management of falls through prevention, investigation, and implementation of interventions. However, the facility did not adhere to this policy, as evidenced by the lack of documented interventions following the falls and the absence of a thorough investigation into the incidents. The Director of Nursing acknowledged the need for interventions after every fall, but these were not consistently implemented or documented in the resident's care plan.
Failure to Monitor Resident Weights
Penalty
Summary
The facility failed to obtain monthly weights for two residents, R13 and R41, which resulted in significant weight loss for R13. R13, who was admitted with diagnoses including cerebrovascular disease and depression, experienced a 15.6% weight loss from November 8, 2024, to February 26, 2025. R13's care plan required monthly weight monitoring, but weights were not recorded for December 2024 or January 2025. R13 was on a mechanically altered diet and required substantial assistance with eating, yet the facility did not adhere to the care plan's weight monitoring requirements. R41, who was on isolation for COVID-19, reported receiving cold meals and expressed uncertainty about recent weight changes. R41's care plan also required monthly weight monitoring due to a diagnosis of moderate protein-calorie malnutrition. However, the last recorded weight for R41 was on December 14, 2024, with no subsequent weights documented. The facility's scale was reportedly broken for about six weeks, contributing to the lack of weight monitoring. The Registered Dietitian (RD) confirmed that no weights were recorded for January 2025 and expressed concern about potential undetected weight loss and malnutrition. The facility's policies required monthly weight monitoring to assess nutritional status and intervene as necessary, but these procedures were not followed. The administrator acknowledged the requirement for monthly weights, yet the facility failed to comply, leading to the deficiency.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was prepared, stored, and distributed in a manner that prevents foodborne illness, potentially affecting all 48 residents. During observations, it was noted that a dietary aide did not check the dish machine sanitizer level. The refrigerators contained items such as a cardboard box of lettuce with sticky, red spatters, an opened container of whipped cream without a date, and various other food items that were not labeled or dated. Additionally, the air conditioner above the toaster was covered in dust, and there were crumbs on a rack of pots and pans next to the stovetop. Further observations revealed that the wall next to the stovetop was spattered with a brown substance, and multiple dented cans of vegetable broth were stored with other cans. In the freezers, there were unlabeled and undated items such as breaded meat patties, pancakes, French fries, and garlic bread. A container of barbecue sauce that required refrigeration after opening was left in the dry storage room. The resident refrigerator contained fast food items that were not labeled or dated. The facility's policies require food to be covered, labeled, and dated, which was not adhered to, as confirmed by the administrator.
Delayed Meal Service for Residents
Penalty
Summary
The facility failed to serve meals in a timely manner for four residents reviewed for nutritional services. Lunch was scheduled to be served at 12:00 PM, but the cook began plating food at 12:13 PM and continued until 1:03 PM. The trays were then taken to the nurse's station to wait for CNAs to deliver them to residents' rooms. The meals were delivered between 1:19 PM and 1:25 PM, significantly later than the scheduled time. A CNA noted that meals are always late, and the administrator acknowledged that while dining room residents are served first, the hall trays should not be delayed. The facility lacks a policy regarding the timeliness of meal service.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two incidents involving residents R15 and R4. Resident R42, who has severe cognitive impairment and a history of aggressive behaviors, was involved in both incidents. In the first incident, R42 was found hitting R15, who is cognitively intact, while R15 was in bed. R15 reported being hit in the face, chest, and breasts by R42, who mistakenly believed R15 was in her room. This incident was documented by an LPN who responded to R15's cries for help. In the second incident, R42 approached R4 in the dining room and hit him in the back with a closed fist. R4, who is also cognitively intact, was eating lunch when the attack occurred. R42's actions were reportedly motivated by jealousy, as she accused R4 of bringing another woman into the dining room. The facility's abuse prevention policy defines abuse as the willful infliction of injury or harm, and these incidents demonstrate a failure to adhere to this policy.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving two residents. In the first incident, a Licensed Practical Nurse (LPN) documented that while passing medicine, they heard a resident calling out and found another resident standing beside the bed, hitting the first resident and telling them to leave the room. Despite this, the facility administrator confirmed that no abuse investigation was conducted for this incident. In the second incident, an LPN was informed by a Certified Nursing Assistant (CNA) that a resident had left their wheelchair, approached another male resident, and hit him on the back. When questioned, the resident accused the male resident of bringing another woman into the dining room. Again, the facility administrator confirmed that no abuse investigation was conducted. The facility's Abuse Prevention Program Policy mandates that all incidents involving abuse, neglect, or misappropriation must result in an investigation, which was not followed in these cases.
Failure to Serve Meals at Desirable Temperatures
Penalty
Summary
The facility failed to serve meals at a desirable temperature to two residents, R14 and R41, as observed during a survey. On February 25, 2025, food temperatures were checked after the last resident tray was served, revealing that while the hamburger and ground hamburger were at acceptable temperatures of 169 and 156 degrees respectively, the French fries and vegetable medley were at lower temperatures of 107 and 123 degrees. R14 expressed dissatisfaction with the food, stating it was cold, tasted bad, and was often served late, sometimes as late as 2:00 PM. R14's Minimum Data Set (MDS) indicated a BIMS score of 15, showing cognitive intactness. R41, who was in isolation for COVID-19, reported receiving cold food that tasted horrible. R41's Face Sheet documented a diagnosis of Moderate Protein Calorie Malnutrition, and the MDS showed a BIMS score of 14, indicating cognitive intactness. The facility's administrator, V1, acknowledged issues with food temperatures due to non-heated meal carts and mentioned ongoing efforts to acquire new carts. The Resident Council Minutes from February 11, 2025, also noted complaints about food not being hot. The facility's Meal Services Temperatures Policy requires hot food to be above 165 degrees and mandates corrective actions if temperatures are not met, but these standards were not adhered to in this instance.
Failure to Adhere to PPE Protocols for Isolated Residents
Penalty
Summary
The facility failed to ensure the proper use of personal protective equipment (PPE) for two residents who were on isolation due to Covid-19. One resident, admitted with type 2 diabetes mellitus and chronic obstructive pulmonary disease, tested positive for Covid-19 and was placed on isolation. However, a Certified Nursing Assistant (CNA) was observed in the resident's room without wearing a gown or gloves, and her mask was improperly positioned below her nose. The CNA justified her lack of PPE by stating she was only passing water. Additionally, the resident's room door was left open, which is against isolation protocols. Another resident, diagnosed with dementia, depression, and anxiety, also tested positive for Covid-19 and was on droplet isolation precautions. Despite this, the resident was seen sitting in the hallway with her mask pulled down below her chin. The facility's administrator stated that staff are expected to follow proper isolation precautions, which include wearing a mask, gown, and gloves in rooms with droplet precautions. The facility's Isolation Precautions Policy supports these measures, indicating a failure to adhere to established protocols for infection control.
Resident Unable to Access Sink Due to Bathroom Layout
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as R34, by not providing access to a sink in the resident's bathroom, which hindered the resident's independence. On February 25, 2025, R34, who is cognitively intact and uses a wheelchair, reported being unable to access the sink in the bathroom to brush his teeth. The bathroom layout, with a toilet riser and grab bars, obstructed wheelchair access to the sink. R34's care plan, dated October 11, 2022, indicated the need for assistance with activities of daily living and environmental adaptations to maximize safety and independence. The Director of Nursing was unaware of this issue until it was brought to her attention during the survey.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post its licensed and unlicensed staffing information responsible for resident care, which has the potential to affect all 48 residents residing in the facility. During a tour of the facility, it was observed that the staffing information was not posted as required. The Director of Nursing indicated that the daily staffing was posted in the employee break room, but the only information available there was the daily assignment sheets for Certified Nurses Assistants and Nurses. These sheets did not include the census or the total number and actual hours worked per shift for the staff responsible for resident care. The Regional Director of Clinical Operations acknowledged the lack of compliance with the policy on daily staff posting and mentioned that this was something they would be implementing.
Failure to Monitor Gastrostomy Tube Site
Penalty
Summary
The facility failed to properly assess and monitor the gastrostomy tube site for a resident, leading to a deficiency in care. The resident, who was moderately cognitively impaired and had a diagnosis of dysphagia and adult failure to thrive, was receiving tube feeding for nutritional support. Despite this, the resident expressed confusion about the necessity of the tube and reported that it had been accidentally removed. The facility's records indicated that the tube was not in place for several days before staff became aware of the situation. Multiple staff members, including nurses and a certified nursing assistant, were involved in the oversight of the resident's care. The resident had informed staff that the tube was out, but there was a lack of immediate action to address the issue. The resident was sent to the hospital for possible reinsertion of the tube after it was discovered missing post-dialysis. An emergency medical technician noted that the tube site was scabbed over, suggesting it had been out for longer than reported, raising concerns about neglect. The facility's policies on enteral feeding tube placement and monitoring were not followed, as evidenced by the lack of documentation and assessment of the tube site. The facility's procedures required checking the tube placement each shift, which was not adhered to, leading to the resident's tube being out for an extended period without proper monitoring or intervention. This failure to follow protocol resulted in the resident requiring hospital observation and potential surgical intervention for tube reinsertion.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving two residents with moderate cognitive impairment who were unable to consent to sexual relations. The deficiency was identified when the facility first noticed inappropriate sexual behaviors between the two residents but did not implement interventions to protect one of the residents from potential abuse. Despite being aware of the situation, the facility allowed the residents to continue interacting without adequate supervision or separation, leading to multiple incidents of inappropriate sexual behavior. The residents involved had diagnoses of dementia and other cognitive impairments, which affected their ability to make informed decisions. The facility's records indicated that the residents were in a relationship, and their families were informed and seemingly accepting of the relationship as long as it was consensual. However, the facility did not take sufficient steps to assess the residents' capacity to consent or to prevent potential abuse, as evidenced by repeated incidents where the residents were found in compromising situations. Staff members were aware of the ongoing interactions between the residents but failed to take appropriate action to prevent further incidents. The facility's documentation and communication with the residents' families and medical professionals were inadequate, as they did not report the incidents to local law enforcement or conduct thorough investigations. The facility's inaction and lack of effective interventions contributed to the continuation of inappropriate behaviors, resulting in a deficiency in protecting residents from abuse.
Removal Plan
- R3 room move to the 200 Hall. R4 room remained on the 300 Hall.
- R3 and R4 were both care planned to maintain supervision when in public areas together. R3 and R4 were care plans to not be in either person's room together.
- R4 was discharged home via AMA per POA.
- The Abuse Assessment was completed for all residents to determine if the resident is at risk of abuse or displays behaviors that would be indicative of potential abuse occurring completed by V1, Administrator.
- All residents identified as at risk for abuse had a care plan developed with interventions to prevent occurrence of abuse completed by V1, Administrator.
- The Administrator, Director of Nursing, and the MDS Coordinator assessed all residents to determine if any other residents were having sexual relationship in the facility. No other resident identified as having a sexual relationship with any resident.
- The Director of Nursing and/or designee educated all staff on what to do when a resident is at risk for abuse or displays behaviors that would be indicative of potential abuse occurring.
- Education will be ongoing to ensure that no employee works prior to receiving education by the Director of Nursing.
- Education will be provided to all new hires prior to working by the Director of Nursing.
- The Director of Nursing, Administrator and/or Social Service Director will assess residents BIMS score for the ability to consent to relationships. If unable to consent, the POA or decision maker will be notified and care plan updated.
Resident Elopement Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident with moderate cognitive impairment. The resident, identified as R5, eloped from the facility sometime after 3:00 AM and was found by a passerby at 6:20 AM. The incident occurred because the door alarm was not activated, as another resident had turned it off. Staff did not notice R5's absence until a round was conducted at 5:00 AM, and an immediate search was initiated both inside and outside the facility. R5 had a history of moderate cognitive impairment, with a BIMS score of 11, and was known to have confusion and forgetfulness. The resident's care plan included interventions for a wander guard and observation of whereabouts, but these measures were not effectively implemented. R5's elopement assessment indicated a risk of elopement, as the resident had previously questioned the need to be at the facility and displayed behaviors suggesting an attempt to leave. Despite these indicators, the facility did not take sufficient precautions to prevent the elopement. Staffing issues were also highlighted, with reports indicating that the number of staff on duty was insufficient to supervise the residents adequately. The layout of the building further complicated supervision, as residents were scattered across different areas, making it difficult for staff to monitor them effectively. The facility's failure to ensure the door alarms were functioning and to provide adequate supervision contributed to the resident's elopement, resulting in Immediate Jeopardy.
Removal Plan
- R5 was immediately placed on 15-minute checks and moved to the 200 Hall for closer supervision.
- R5's care plan was reviewed and updated to reflect interventions regarding elopement risk by the MDS Coordinator.
- R5 was discharged home with R5's emergency contact.
- The Elopement Assessment was completed on all residents by V1, Administrator.
- All residents identified at risk for elopement care plans were updated with interventions, as well as the facility's Code Yellow Binder by V1, Administrator.
- All staff were in-service on the facilities Elopement Prevention Policy to reflect on what to do in the event of a missing person. All staff Education will be ongoing to ensure that no one works prior to being in-service by the Director of Nursing.
- All policies and procedures related to elopement and missing person were reviewed to ensure appropriate by V26, Regional Director and V1, Administrator.
- The Maintenance Director audited all exit door to ensure alarms are functioning properly.
- Door alarm code was changed and staff in serviced by the maintenance director on new code and not giving out the code to family members or residents.
Failure to Investigate and Prevent Sexual Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse to prevent further sexual abuse for two residents with moderate cognitive impairment, who were unable to consent to sexual relations. The report details multiple incidents where one resident displayed sexual behaviors towards another, including fondling and being found in compromising situations with their pants down. Despite these incidents, the facility did not conduct thorough investigations or implement effective interventions to prevent further occurrences. The report highlights several documented incidents involving the two residents. One resident was observed entering male residents' rooms and engaging in inappropriate behaviors, while the other resident was found in similar situations with female residents. Progress notes indicate that these behaviors were ongoing, with staff documenting the incidents and notifying family members and the administrator. However, there was a lack of formal investigations or comprehensive interventions to address the behaviors and protect the residents involved. The facility's Abuse Prevention Program Policy mandates that any incident or allegation of abuse should result in an investigation. Despite this policy, the Director of Nursing confirmed that no investigations were conducted for the incidents involving the two residents, except for one on a specific date. The facility's response was limited to documenting the incidents in progress notes and notifying medical professionals and family members, without taking further action to prevent recurrence.
Failure to Implement Abuse Policy for Residents with Dementia
Penalty
Summary
The facility failed to implement its abuse policy to protect a resident's right to be free from sexual abuse by a known male with sexual behaviors. This deficiency involved two residents, both diagnosed with dementia, who were in a relationship that included holding hands and kissing. Despite the facility's awareness of the residents' cognitive impairments and the need to keep them apart, the staff did not effectively prevent them from being alone together. On two occasions, the residents were found with their pants and underwear off in one of the resident's rooms, indicating a failure to maintain adequate supervision and separation. The facility's administrator acknowledged the difficulty in keeping the residents apart and admitted that neither resident had the cognitive capacity to consent to a sexual relationship. The facility reported only one of the incidents to the state agency and did not report any incidents to local law enforcement, as they were uncertain if the situation constituted abuse. The facility's abuse prevention policy requires immediate reporting and investigation of any incident or suspicion of abuse, which was not fully adhered to in this case.
Inadequate Staffing Levels Compromise Resident Care
Penalty
Summary
The facility failed to maintain adequate staffing levels, particularly during the night shift, which compromised the ability to meet the needs of all 47 residents. On the night of October 3, 2024, only two CNAs and one LPN were on duty, which was insufficient to provide necessary care and supervision. The CNAs were also required to perform laundry duties, further detracting from their ability to focus on resident care. Staff expressed concerns about the inability to answer call lights promptly and supervise residents, especially those at risk for falls. Despite these challenges, management cited financial constraints as a reason for not increasing staff levels. Interviews with staff and residents highlighted the impact of inadequate staffing on resident care. A CNA reported that the current staffing levels made it difficult to provide timely care and supervision, particularly for residents at risk of falls. An LPN contracted to work at the facility expressed surprise at the low staffing levels and noted the difficulty in supervising residents due to the building's layout. Residents also voiced concerns, with one resident mentioning missed showers and delayed responses to call lights, which they attributed to the lack of staff. The facility's Director of Nurses (DON) acknowledged the staffing challenges but maintained that the current staffing ratios were based on the number of residents. The DON indicated that additional staff would be added once the census increased to 50 residents. However, the facility's assessment and staffing calculations suggested a need for more nursing hours than were being provided. The facility's layout and the distribution of residents across different halls further complicated the ability to provide adequate supervision and care, as noted by both staff and residents.
Failure to Report Potential Sexual Abuse Incidents
Penalty
Summary
The facility failed to report potential sexual abuse involving two residents, both diagnosed with dementia, to the local police department and the State Agency. An incident occurred where one resident was found in another resident's room with their pants down, and the other resident was on top of them. Despite the residents' Power of Attorneys being informed and expressing no concerns if the relationship was consensual, the facility did not notify law enforcement or the residents' physicians about the potential abuse. The facility's records indicate multiple incidents involving inappropriate sexual behavior between the two residents and other residents. These incidents included one resident being found with their hand down another resident's shirt and another incident where a resident was observed with their hand on another resident's leg. Despite these occurrences, the facility did not conduct thorough investigations or report these incidents to the appropriate authorities, as required by their Abuse Prevention Program Policy. Interviews with facility staff revealed that they were aware of the incidents but did not take the necessary steps to report them. The Director of Nursing and the Administrator acknowledged that only one incident was reported to the State Agency, and none were reported to local law enforcement. The facility's policy mandates immediate reporting of such incidents to both the state survey agency and local law enforcement, which was not adhered to in these cases.
Failure to Timely Address and Monitor UTI
Penalty
Summary
The facility failed to address and monitor a urinary tract infection (UTI) in a timely manner for a resident, identified as R2, who was part of a sample of six residents reviewed for UTIs. R2 had multiple diagnoses, including a UTI, and was frequently incontinent of urine and bowel. The resident's care plan included monitoring for skin integrity and toileting needs, but there was a delay in obtaining and processing the necessary lab work to confirm and treat the UTI. The resident's family expressed concerns about the facility's handling of the UTI, noting that the facility would not test for a UTI unless the resident developed a fever. The family believed that the resident still had a UTI and that there was a delay in ordering and receiving lab results, which led to a serious infection. The facility's progress notes indicated multiple attempts to obtain a urine sample and confusion over lab orders, resulting in a delay in diagnosis and treatment. The Director of Nursing acknowledged a mix-up in the lab orders, which contributed to the delay in obtaining a culture and sensitivity report. The hospital lab manager confirmed that the facility did not order the correct lab work initially, leading to the delay. The facility's Laboratory Report Policy required nurses to ensure all labs were performed as ordered and to notify physicians of results, but this process was not followed, resulting in the deficiency.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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