La Bella Of Alton
Inspection history, citations, penalties and survey trends for this long-term care facility in Alton, Illinois.
- Location
- 3490 Humbert Road, Alton, Illinois 62002
- CMS Provider Number
- 145651
- Inspections on file
- 56
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at La Bella Of Alton during CMS and state inspections, most recent first.
A resident with dementia and type 2 DM had physician orders for Humalog insulin per sliding scale at meals and bedtime and for routine blood glucose monitoring. Over two consecutive days, scheduled blood sugar checks and insulin doses were not documented as completed, and progress notes contained no evidence that the physician was notified of the missed monitoring and medication. An LPN reported that the resident had behavioral issues, then slept for an extended period, and the LPN chose not to check blood sugars or give insulin during this time and did not contact the physician, contrary to facility policies on change-of-condition notification and medication errors.
A resident with dementia and type 2 DM with hyperglycemia had physician orders for scheduled Insulin Glargine, Humalog per sliding scale at meals and bedtime, and blood glucose monitoring, all reflected in the care plan. Over multiple ordered times across two days, the MAR shows that blood sugars were not checked and Humalog was not administered. Progress notes indicated the resident slept extensively during this period, and an LPN reported she chose not to perform blood glucose checks or give insulin because the resident was sleeping, despite facility policy requiring blood glucose monitoring per physician orders and the administrator’s expectation that such monitoring be completed as prescribed.
A resident with dementia and Type 2 DM with hyperglycemia did not receive ordered Insulin Glargine and Humalog sliding scale doses, nor scheduled blood glucose (BG) checks, over multiple administration times. The care plan called for diabetes medications and BG monitoring per physician orders, but the MAR showed several missed insulin administrations and BG checks. Later, staff were called by a CNA at the request of the resident’s daughter because the resident was clammy and difficult to arouse; vital signs were taken, an initial BG was 230, and a repeat BG reading registered “HI.” The facility’s Administrator stated insulin was expected to be given as ordered, and the medication error policy required medications to be administered according to physician orders.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to accident prevention.
A resident with severe cognitive impairment and a history of urinary incontinence did not receive complete peri-care after a bowel movement, as staff failed to clean the front perineal area before applying a new brief. This action was inconsistent with facility policy and standard CNA practice, as confirmed by staff interviews.
Two residents with indwelling urinary catheters did not receive catheter care and catheter changes as ordered by their physicians. One resident's catheter was not changed monthly as required, and another did not receive catheter care every shift. Staff interviews and resident statements confirmed that care was missed or not performed according to orders.
A facility failed to prevent verbal abuse between two residents, one of whom frequently called the other derogatory names related to incontinence in public areas. Despite staff awareness, the verbal abuse continued, indicating a failure to enforce the facility's abuse prevention policy.
A resident admitted post-abdominal surgery did not receive a wound vac as ordered in the hospital discharge paperwork. Instead, the facility's wound specialist opted for an alternative treatment, believing the wound was healing. The wound vac was applied several days later, contrary to the discharge instructions. The Director of Nurses noted the resident was admitted without specific orders, leading to the alternative treatment until clarification was obtained.
The facility failed to provide scheduled showers and document hygiene care for four residents, leading to poor personal hygiene and discomfort. Residents reported not receiving showers for weeks, and staff interviews revealed inconsistencies in documentation practices. The facility's policy to assist residents with ADLs was not followed, resulting in a deficiency.
A resident's right to a preferred shower schedule was not upheld when her shower time was changed from day to evening without her consent, despite her care plan documenting her preference for day showers due to safety concerns with evening medications. The facility's policy emphasizes resident rights, but this was not followed, leading to a deficiency.
The facility failed to respond to call lights in a timely manner for three residents, leading to inadequate care. One resident with cognitive impairments reported 20-minute delays, while another with a muscle disease expressed frustration over long waits, especially at night. A third resident with amputations noted worsening response times. Grievance reports highlighted multiple complaints, including a four-hour wait for assistance. Staffing shortages were cited as a factor, and the facility lacks specific policies on call light responses.
The facility failed to update and document the advanced directives for two residents, leading to inappropriate life-saving measures for one resident who had a DNR status. Poor communication and documentation practices resulted in incorrect information being provided to EMS, and the resident's POA was not informed of the hospital transfer. Another resident's documentation also contained discrepancies between the POLST and POA paperwork.
The facility failed to notify the responsible parties of two residents before transferring them to an acute care facility. One resident, with a DNR order, was intubated due to incorrect paperwork, leading to his death. Another resident was transferred for surgery without notifying her POA. Staff interviews revealed inconsistencies in following procedures for notifying family members and preparing transfer documentation.
A resident did not receive her prescribed dose of Levothyroxine as scheduled, according to the MAR for August 2024. The resident, who is alert and oriented, reported that an agency nurse failed to administer her thyroid medication at the scheduled time. The DON confirmed the resident was present and should have received the medication as ordered.
A resident with ESRD and multiple health conditions became unresponsive at the facility but was later sent to dialysis without informing the center of the incident. The dialysis center was unaware of the earlier unresponsiveness, leading to the resident coding during treatment and later expiring at the hospital. The facility failed to complete and provide the necessary communication form to the dialysis center, resulting in a lack of continuity of care.
The facility failed to follow its COVID-19 testing policy, resulting in delayed testing for residents exposed to the virus. Additionally, an LPN did not use proper PPE or clean equipment after caring for a COVID-19 positive resident. The facility also lacked signage indicating a COVID-19 outbreak, compromising infection control measures.
The Facility failed to employ a qualified Infection Preventionist (IP) with the necessary specialized training, as the current ADON/IP is not yet certified. In the interim, the DON and MDS Coordinator, who have full-time roles, are overseeing infection control. This deficiency occurred despite the Facility's policy requiring the IP to be qualified by education, training, experience, and/or certification. The Facility has been in COVID-19 Outbreak Status, affecting all 126 residents.
A resident did not receive prescribed medications, Levoxyl and Omeprazole, due to their unavailability, leading to an 8% medication error rate. An LPN could not find the medications on the cart, and another LPN later found the Levoxyl in the medication room but did not administer it. The facility's policy lacks guidance for handling unavailable medications.
A resident with no cognitive deficits was not informed about changes to their shower schedule, leading to missed therapy and dissatisfaction. The resident preferred evening showers, which were not accommodated, resulting in a grievance. Staff confirmed the schedule changes were not communicated, and the DON was unaware of the grievance. The facility's policy on ADLs was not followed.
The facility failed to provide adequate showering assistance to four residents, leading to deficiencies in personal hygiene care. Residents reported infrequent showers, with some not receiving showers for weeks despite needing assistance due to medical conditions. Observations confirmed residents appeared unkempt, and staff interviews revealed inconsistencies in documentation and shower provision.
The facility failed to ensure required physician visits for several residents, with no documented medical doctor progress notes for 2024. Despite frequent visits by a physician assistant, the primary medical doctor had not been seeing residents every 60 days as required by the facility's policy and OBRA regulations.
The facility failed to provide sufficient staffing during evening and night shifts, leading to long wait times for residents needing assistance. Multiple residents and staff reported delays in care due to inadequate staffing levels, particularly during call-offs. The facility's policies and resident council meeting minutes confirmed ongoing concerns about staffing shortages.
A facility failed to follow a surgeon's recommendation for a resident's medication change, leading to the resident receiving an incorrect dosage of Levothyroxine for over two months. Despite multiple communications from the Radiation Oncology clinic and the Endocrinologist, the facility did not properly document or follow up on the correct dosage, resulting in side effects for the resident.
A facility failed to administer medications as ordered for a resident, with an LPN giving incorrect dosages of Folic Acid, Lamotrigine, and Sertraline, and failing to administer Symbicort. The errors were attributed to the LPN's nervousness during an observed medication pass.
The facility failed to provide therapeutic diets as ordered by the physician for two residents. One resident with severe malnutrition did not receive double protein portions for eight days, and another resident did not receive prescribed super cereal and ice cream. The Dietary Manager was unaware of the orders, indicating a lack of communication and adherence to dietary guidelines.
Failure to Notify Physician and Administer Ordered Insulin for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a change in condition and the holding of ordered diabetic medication for one resident. The resident was admitted with dementia and type 2 diabetes mellitus with hyperglycemia and had physician orders for Humalog insulin per sliding scale at meals and bedtime, along with care plan interventions for diabetes medication administration and blood sugar monitoring. Additional physician orders directed staff to monitor for signs and symptoms of hypoglycemia and hyperglycemia. The Medication Administration Record shows that on multiple occasions over two consecutive days, the resident’s blood sugar was not checked and Humalog insulin was not administered at scheduled times. Progress notes do not document any notification to the physician regarding the missed blood sugar checks or insulin doses. An LPN reported that on one of those days the resident was having behaviors and combativeness, later went to sleep, and remained sleeping the following day. The LPN stated she did not check the resident’s blood sugars or administer insulin because she felt sleeping was best for the resident and did not notify the physician of this. The facility’s policies on notification of changes and medication errors require prompt physician notification when there is a change requiring notification or when a medication error occurs, but there is no documentation that such notification occurred in this case.
Failure to Perform Ordered Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered blood glucose monitoring and insulin administration for a resident with known type 2 diabetes mellitus with hyperglycemia. The resident was admitted with dementia and diabetes, was cognitively impaired, ambulated with supervision, and was care planned for potential high and low blood sugar with interventions including diabetes medication and blood sugar checks as ordered by the physician. Physician orders directed administration of Insulin Glargine 40 units twice daily and Humalog per sliding scale at meals and at bedtime, along with monitoring for signs and symptoms of hypo- and hyperglycemia. Despite these orders, the Medication Administration Record shows that on multiple ordered times over two consecutive days, the resident’s blood sugar was not checked and Humalog was not administered. During this period, a progress note documented that the resident had been sleeping since the start of a night shift and continued to sleep a lot into the following day. An LPN later stated that the resident had exhibited behaviors and combativeness, then finally went to sleep and remained very sleepy, and that she did not check the resident’s blood sugars or give insulin because she felt sleeping was best for the resident at that time. The administrator stated an expectation that nurses monitor blood glucose levels as prescribed by the physician. The facility’s Blood Glucose Monitoring Policy in effect at the time required that blood glucose monitoring be performed for diabetic residents as per physician orders, but this was not followed for this resident during the identified time frame.
Failure to Administer Ordered Insulin and Perform Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to administer ordered subcutaneous insulin and perform ordered blood glucose monitoring for a resident with dementia and Type 2 diabetes mellitus with hyperglycemia. The resident’s MDS documented cognitive impairment and insulin use, and the care plan identified a potential for high and low blood sugar with interventions including diabetes medications and blood sugar checks as ordered by the physician. The MAR for the month showed a physician’s order for Insulin Glargine 40 units twice daily that was not administered on three documented occasions, and a Humalog sliding scale insulin order before meals and at bedtime that was not administered on multiple documented occasions over two consecutive days. Additionally, the MAR documented an order for blood glucose monitoring before meals and at bedtime that was not completed at several scheduled times during the same period. A progress note later documented that staff were called to the resident’s room by a CNA at the request of the resident’s daughter, who reported the resident was clammy. Vital signs were recorded as 97.0, 74, 14, and 90/70, and an initial blood glucose check showed a reading of 230. The note stated the resident was unable to be aroused and had shallow breathing, and when the nurse voiced concern about the breathing pattern, the daughter stated that was how the resident breathed when sleeping. A subsequent progress note documented that a second blood glucose check at that time read “HI.” The Administrator stated she would expect insulin to be given as ordered, and the facility’s Medication Error Policy stated that medications shall be administered according to physician’s orders.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Incomplete Peri-Care Provided to Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses including hemiplegia, dementia, and schizophrenia, who was severely cognitively impaired and dependent on staff for activities of daily living, did not receive complete incontinent care. The resident was observed after a bowel movement to have her rectal area wiped by a CNA, but the front perineal region was not cleaned before a new brief was applied and her clothing was replaced. This incomplete peri-care was inconsistent with the facility's policy, which requires thorough cleaning of both the perineal and rectal areas for female residents, wiping from front to back. Interviews with other CNAs confirmed that standard practice is to clean both the front and back perineal areas after incontinence or toileting. The administrator also stated that the expectation is for peri-care to be performed completely. The failure to provide complete peri-care was documented for one resident who had a recent physician's order for antibiotics to treat a urinary tract infection, highlighting the importance of proper care in this context.
Failure to Provide Physician-Ordered Catheter Care and Timely Catheter Changes
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters as ordered by physicians. For one resident with a cervical spinal cord injury and neurogenic bladder, the physician's order required monthly catheter changes and catheter care every shift. However, the resident reported that the catheter had not been changed since admission, and the responsible nurse acknowledged missing the order due to it being combined with another order. The care plan and medical record confirmed the need for regular catheter changes and care, but these were not performed as prescribed. Another resident with acute kidney failure and neurogenic bladder had a physician's order for catheter care every shift and as needed. The resident stated that staff did not clean the catheter every shift, and two CNAs confirmed that catheter care had not been performed for this resident during their shifts. The facility's policy emphasized the importance of catheter care to prevent complications, but staff interviews and resident statements indicated that care was not provided according to orders.
Failure to Prevent Verbal Abuse Among Residents
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by the interactions between two residents, R2 and R3. R2, who is cognitively intact and has a history of schizoaffective disorder and bipolar disorder, reported being verbally abused by R3, who has a history of mental and behavioral disorders and substance abuse. R3, who is moderately cognitively impaired, frequently called R2 derogatory names related to R2's incontinence, such as 'S***typants,' in common areas like the dining room. Despite staff awareness of these incidents, including reports from an LPN and a Dietary Aid, the verbal abuse continued, indicating a failure to effectively address and prevent the behavior. Interviews with staff and other residents corroborated the ongoing verbal exchanges between R2 and R3, with both residents reportedly picking on each other. However, R3's behavior was noted to be more persistent and public, as he would often make derogatory remarks in front of others. The facility's policy on abuse prevention, which mandates freedom from verbal abuse, was not effectively enforced, as staff, including the Social Services Director, were aware of the situation but did not prevent the continuation of the verbal abuse. This deficiency highlights a lapse in the facility's responsibility to ensure a safe and respectful environment for all residents.
Failure to Follow Hospital Discharge Orders for Wound Care
Penalty
Summary
The facility failed to follow the physician's hospital discharge order for a resident who was admitted post-abdominal surgery with multiple ostomies and lower bowel ischemia. The hospital discharge paperwork specified that a wound vac should be applied to the resident's abdominal wound starting on the day of discharge. However, the wound vac was not applied until several days later, as documented in the Treatment Administration Record. Instead, an alternative treatment was administered based on the facility wound specialist's decision, who believed the wound was healing and did not require a wound vac. The Director of Nurses acknowledged that the resident was admitted as an emergency from the ER without specific abdominal wound orders, leading to the facility's wound specialist providing alternative treatment. Despite the resident's insistence on needing a wound vac, the wound care specialist maintained that the wound was improving without it. The facility's policy requires that all medication and treatment orders be consistent with safe and effective order writing, yet there was a lapse in following the hospital's discharge orders, resulting in a delay in applying the wound vac as initially prescribed.
Deficiency in Showering and Hygiene Documentation
Penalty
Summary
The facility failed to ensure that residents received showers as per their care plans, resulting in a deficiency in providing necessary assistance with activities of daily living (ADLs). Four residents were identified as not having received showers according to their scheduled days, and there was a lack of documentation to indicate whether showers were given or refused. This failure was observed through interviews, record reviews, and direct observations of the residents' conditions. Resident 2, who requires substantial assistance with personal care, reported not having had a shower in about four weeks, which was corroborated by the lack of documentation in the facility's records. The resident expressed discomfort and concern about attending an appointment due to feeling unclean. Similarly, Resident 4, who is a bilateral amputee and requires maximal assistance, reported not being showered or shaved, and observations confirmed poor hygiene. Resident 1 also reported infrequent showers and poor personal hygiene, with observations noting unclean fingernails. Resident 3, who is cognitively impaired, had only one documented shower for the month, despite being scheduled for more. Interviews with staff revealed inconsistencies in documentation practices, with CNAs stating they document showers in a shower book, but the records did not reflect this. The LPN noted that some residents refuse showers, but there was no documentation to support refusals for the residents in question. The facility's policy requires that residents unable to perform ADLs independently receive necessary services to maintain hygiene, which was not adhered to in these cases.
Failure to Uphold Resident's Right to Preferred Shower Schedule
Penalty
Summary
The facility failed to uphold the resident's right to a dignified existence and self-determination for one resident (R2) who was reviewed for resident rights. R2, who was admitted with a diagnosis requiring assistance with personal care, expressed a preference for showering during the day shift due to the effects of her evening medications, which made her feel unsafe using a mechanical lift. Despite this preference being documented in her care plan, her shower schedule was changed to evenings without her consent, leading to her discomfort and concerns about safety. The Director of Nurses (DON) was informed by a Certified Nursing Assistant (CNA) that R2 wanted to switch back to day shift showers, but this change was not communicated to the Regional Clinical of Operations, who was unaware of R2's preference. The facility's Resident Rights Policy, revised in 2021, emphasizes the importance of treating residents with respect and dignity and supporting them in exercising their rights, including participating in care planning and decision-making. However, the facility failed to adhere to this policy, resulting in a deficiency in upholding R2's rights.
Delayed Call Light Responses in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner for three residents, leading to a deficiency in providing adequate and timely care. Resident 1, who has type 2 diabetes mellitus, congestive heart failure, and cognitive impairments, reported that staff usually take around 20 minutes to respond to call lights, which she feels is too long. She was found in a saturated incontinent brief, indicating a delay in care. Resident 3, who is cognitively intact and requires extensive assistance with activities of daily living, expressed frustration with the long response times, especially during the midnight shift, and mentioned needing to remind staff to turn her every two hours due to a muscle disease. Resident 7, who has type 2 diabetes mellitus and amputations, also reported long wait times for call light responses, stating that the situation has worsened over time. The facility's grievance reports document multiple complaints about delayed call light responses, including a report of a resident waiting four hours for assistance. Staff interviews revealed that call light response times are affected by staffing shortages, with a CNA noting difficulties in responding timely when short-staffed. The Director of Nursing expects timely responses, but the facility lacks specific policies on call lights or resident rights, as confirmed by the Administrator.
Failure to Update and Document Advanced Directives
Penalty
Summary
The facility failed to update and maintain accurate documentation regarding the Code Status/Advanced Directives for two residents, leading to significant consequences. Resident R3 had clearly indicated a Do Not Resuscitate (DNR) status in his advanced directive, but due to the facility's failure to correctly identify and document this status, R3 was subjected to life-saving measures, including intubation, which were against his wishes. The facility provided Emergency Medical Services (EMS) with incorrect paperwork indicating R3 was a Full Code, resulting in inappropriate medical interventions at the hospital. The situation was exacerbated by poor communication and documentation practices within the facility. The nurse on duty at the time of R3's emergency was unfamiliar with his medical history and could not provide EMS with accurate information. Additionally, the facility failed to notify R3's brother, who was his Power of Attorney (POA), about the transfer to the hospital. This lack of communication and the incorrect documentation led to R3's brother having to make the difficult decision to withdraw care after discovering the error at the hospital. Similarly, Resident R4's documentation also contained discrepancies between the POLST and the POA paperwork. R4's POLST indicated a Full Code status, while the POA paperwork stated that R4 did not want life-prolonging treatments. These inconsistencies highlight a systemic issue within the facility regarding the management and updating of advanced directives, which are crucial for ensuring that residents' end-of-life wishes are respected and followed.
Failure to Notify Responsible Parties Before Resident Transfers
Penalty
Summary
The facility failed to notify the responsible parties of two residents prior to their transfer to an acute care facility, resulting in significant deficiencies. For the first resident, who had a history of chronic obstructive pulmonary disease (COPD), respiratory failure, and other serious health conditions, the facility did not inform the resident's Power of Attorney (POA) before transferring him to the emergency room. Upon arrival at the hospital, the resident was found to be in severe respiratory distress and was intubated based on incorrect paperwork indicating he was a Full Code, despite having a Do Not Resuscitate (DNR) order. This error led to the resident being intubated against his wishes, and he subsequently passed away after the error was corrected. The second resident, who had multiple health issues including metabolic encephalopathy and gangrene, was transferred to a hospital for surgery without the facility notifying her POA. The resident's family member reported that the facility did not inform them of the transfer or the impending surgery, which was only discovered when the hospital contacted the family for consent. The facility's failure to communicate with the resident's POA resulted in a lack of awareness and preparation for the resident's significant medical procedure. Interviews with facility staff revealed inconsistencies in the process of notifying family members and preparing transfer documentation. Staff members described their procedures for handling emergency transfers, which included notifying the physician and preparing necessary paperwork, but these procedures were not followed in the cases of the two residents. The facility's policy on transfers and discharges requires timely notification to residents and their representatives, which was not adhered to in these instances, leading to the deficiencies noted in the report.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for a resident reviewed for medication administration. The resident, who is alert and oriented, reported that an agency nurse did not provide her with her prescribed thyroid medication, Levothyroxine, at the scheduled time of 4:30 AM. The resident could not identify the nurse or recall the specific date of the incident. However, a review of the Medication Administration Record (MAR) for August 2024 revealed that the resident did not receive her scheduled dose of Levothyroxine on August 12, 2024. The Director of Nursing confirmed that the resident was present in the facility on that date and should have received her medication as ordered by the physician. The facility's policy on administering medications emphasizes that medications should be administered safely, timely, and as prescribed.
Failure in Communication and Continuity of Care for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication and continuity of care between the facility and the dialysis center for a resident with end-stage renal disease (ESRD) and multiple other health conditions, including congestive heart failure and diabetes. The resident was scheduled to receive dialysis three times a week. On the morning of the incident, the resident became unresponsive while interacting with staff, prompting a call to emergency services. However, the resident regained consciousness, refused transport to the emergency room, and was later sent to the dialysis center without any communication of the earlier incident. The dialysis center was not informed of the resident's earlier unresponsiveness, which was a critical oversight. The dialysis center's staff, including the RN Clinical Manager and the Dialysis Medical Director, stated that had they been informed of the resident's condition earlier in the day, they would have taken precautionary measures, such as rescheduling the dialysis appointment or ensuring the resident was evaluated at a hospital before treatment. Unfortunately, the resident coded during dialysis and was taken to the hospital, where she later expired. The facility's Director of Nursing and Administrator acknowledged the lack of documentation and communication with the dialysis center. The facility had a protocol involving a communication form to be filled out and shared with the dialysis center, detailing any changes in the resident's condition and medications. However, there was no evidence that this form was completed or provided to the dialysis center on the day of the incident, leading to a significant lapse in the continuity of care for the resident.
Inadequate COVID-19 Testing and Infection Control Measures
Penalty
Summary
The facility failed to operationalize its infection prevention and control program, particularly in testing and tracking COVID-19 among residents. The report highlights several instances where residents were not tested for COVID-19 in a timely manner following exposure to infected roommates. For example, one resident was not tested until four days after returning from the hospital, despite the facility being in an outbreak status. Another resident was not tested immediately after their roommate tested positive, and similar delays were noted for other residents, indicating a pattern of non-compliance with the facility's COVID-19 testing policy. Additionally, the facility did not adhere to proper infection control practices regarding the use of personal protective equipment (PPE) and the cleaning of multi-use equipment. An LPN was observed entering a resident's room, who was on droplet precautions for COVID-19, without wearing the required PPE and failed to clean the equipment used on the resident. This lapse in protocol was acknowledged by the facility's administrator, who stated that staff should be using disposable equipment for isolation residents. Furthermore, the facility did not post signage indicating it was in a COVID-19 outbreak, as required by its policy. Upon entrance, there were no visual alerts or postings to inform visitors and staff of the outbreak status, which is a critical component of infection prevention and control. The Director of Nurses confirmed the outbreak status, yet the lack of signage suggests a failure to communicate this important information effectively.
Facility Lacks Qualified Infection Preventionist
Penalty
Summary
The Facility failed to employ a qualified Infection Preventionist (IP) with the necessary specialized training to manage the infection prevention and control program effectively. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) admitted to not having the IP certification but is currently undergoing training. In the interim, the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator, who both have full-time roles, are overseeing infection control. This situation arose despite the Facility's policy requiring the infection preventionist to be qualified by education, training, experience, and/or certification, with evidence of specialized IPC training prior to assuming the role. The Facility has been in COVID-19 Outbreak Status since early July, affecting all 126 residents.
Medication Error Due to Unavailable Prescribed Medications
Penalty
Summary
The facility failed to provide physician-prescribed medications, resulting in a medication error rate of 8%, which exceeds the acceptable threshold of 5%. This deficiency involved a resident, R13, who was prescribed Levoxyl and Omeprazole to be administered at 5:00 AM. On the morning of July 23, 2024, an LPN, V12, was unable to locate these medications on the medication cart, stating that they had been ordered but had not yet arrived. Later that day, another LPN, V13, found the Levoxyl in the medication room and noted that Omeprazole is available over the counter, but confirmed that neither medication was administered during her shift. The facility's medication administration policy, dated April 2019, requires medications to be administered according to prescriber orders but does not specify procedures for when medications are unavailable.
Failure to Communicate Shower Schedule Changes
Penalty
Summary
The facility failed to accommodate and inform a resident, identified as R5, about a change in their shower schedule, which led to dissatisfaction and a grievance being filed. R5, who has no cognitive deficits and requires partial assistance with showering, was upset about the uncommunicated change in the shower schedule, which caused them to miss a therapy session. The resident expressed a preference for evening showers on specific days, which was not honored, leading to R5 refusing showers in protest. The grievance filed by R5 highlighted the lack of communication regarding the schedule changes and the impact on their daily routine. Interviews with staff and other residents' representatives revealed that the shower schedule changes were not communicated effectively, causing confusion and dissatisfaction among residents. A Certified Nursing Assistant confirmed that the schedule was still being worked out and that residents' preferences were not being accommodated. The Director of Nursing was unaware of the grievance filed by R5 and stated that the schedule could be adjusted to meet residents' preferences. The facility's policy on activities of daily living emphasizes providing appropriate care and services with resident consent, which was not adhered to in this case.
Deficiency in Showering Assistance for Residents
Penalty
Summary
The facility failed to provide adequate showering assistance to four residents, resulting in deficiencies in personal hygiene care. Resident R2, who requires assistance with personal care due to multiple medical conditions including cerebral ischemia and schizoaffective disorder, reported not having a shower for about two weeks despite requesting one. Observations confirmed R2 appeared unkempt with dried food on her body. Similarly, Resident R5, with diagnoses such as Alzheimer's disease and chronic kidney disease, stated he usually receives a shower every 2-3 weeks, although he desires at least two showers per week. On the day of observation, R5 appeared disheveled and unshaven. Resident R6, who is dependent on staff for bathing due to conditions like Parkinson's disease and vascular dementia, reported not having a shower in about a month, with only one documented shower in June. R6 was observed with food stuck to his clothing. Resident R17, requiring maximum assistance due to conditions like COPD and end-stage kidney disease, had not received a shower since moving rooms three weeks prior. The facility's documentation practices were inconsistent, with CNAs either not completing showers or failing to document them, as noted by staff interviews. The facility's policy mandates assistance with hygiene for residents unable to perform activities of daily living independently, which was not adhered to in these cases.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a physician as required, affecting four out of seven residents reviewed for physician visits. Resident 2, who is cognitively intact, reported only seeing her medical doctor once at admission two years ago, with no documented medical doctor progress notes for 2024. Resident 5, who is moderately cognitively impaired, also lacked any physician visits documented for 2024. Similarly, Resident 18, with moderate cognitive impairment, and Resident 21, who is cognitively intact, had no medical doctor progress notes for the year. The facility's administrator acknowledged the absence of physician progress notes for these residents and noted that the physician assistant frequently visits the facility, but the primary medical doctor had not been seeing residents every 60 days as required. The facility's Physician Services Policy mandates that medical care is supervised by a licensed physician, with visits in accordance with OBRA regulations. The medical director admitted to not visiting residents unless they were newly admitted or receiving skilled services, indicating a lapse in compliance with the facility's policy and federal regulations.
Insufficient Staffing During Evening and Night Shifts
Penalty
Summary
The facility failed to sufficiently staff the facility to meet the needs of residents, particularly during evening and night shifts. Multiple residents reported long wait times for assistance, with one resident stating it took three hours to receive help after an incontinent episode. Another resident's daughter decided to discharge her mother due to insufficient staffing observed during a visit. Staff members, including CNAs and LPNs, confirmed that call-offs and inadequate staffing levels often left them unable to promptly respond to residents' needs, especially during night shifts. Observations and interviews revealed that the facility often operated with only one nurse and one CNA per resident hall, leading to delays in answering call lights and providing necessary care. Managers were seen assisting with call lights due to the lack of available CNAs. The staffing coordinator admitted to using the state's staffing calculator but acknowledged that call-offs frequently left the facility understaffed. The assistant director of nursing and other staff members also confirmed the need for more help during evenings and nights, particularly when admissions increased during these times. The facility's daily staffing sheets and resident council meeting minutes further documented the ongoing issues with staffing. The resident council had repeatedly raised concerns about long wait times for call lights to be answered and the need for more staff during evenings and nights. The facility's policies stated that calls for assistance should be answered within five minutes, but this standard was not being met. The facility's owner acknowledged the need for staffing based on resident needs rather than just meeting state minimum requirements.
Failure to Follow Medication Change Recommendation
Penalty
Summary
The facility failed to follow through on a recommendation for a medication change for a resident (R2) who was supposed to start taking Levothyroxine 137 mcg daily after being declared cancer-free by his surgeon. Despite the surgeon's instructions and subsequent confirmation from the Radiation Oncology clinic, the facility's Medical Director initially prescribed a different dose of Levothyroxine (112 mcg), which was not corrected until months later. This discrepancy led to the resident's Endocrinologist expressing concern over the medication change without consultation and the resident experiencing side effects due to the incorrect dosage. The resident's medical records and progress notes indicate that the facility received multiple communications from the Radiation Oncology clinic and the Endocrinologist regarding the correct dosage of Levothyroxine. However, these instructions were not properly documented or followed up on by the facility staff. The resident's Medication Administration Record (MAR) shows that the resident did not receive any thyroid replacement therapy until nearly a month after the initial order and continued on the incorrect dosage for over two months. Interviews with facility staff, including nurses and the administrator, revealed a lack of proper follow-up and documentation procedures for residents returning from outside medical appointments. The staff admitted that they should have contacted the medical offices to confirm any new orders or changes in treatment, especially given the resident's recent thyroid removal and cancer treatment. The facility also lacked a specific policy for obtaining and following up on information after residents' outside medical appointments.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident. During an observed medication pass, an LPN administered incorrect dosages of multiple medications. Specifically, the LPN gave only one tablet of Folic Acid instead of three, one tablet of Lamotrigine instead of two, and one tablet of Sertraline instead of two. Additionally, the LPN did not administer the Symbicort inhaler as ordered. The LPN counted the pills in the medication cup and incorrectly stated there were 11 pills when there should have been 15, indicating multiple errors in medication administration. The Director of Nursing later documented that some of the missed medications were administered late with physician approval, but there was no documentation that the correct dose of Lamotrigine was given. The LPN and the Director of Nursing acknowledged the errors, attributing them to the LPN's nervousness during the observed medication pass. The facility's policy requires medications to be administered as prescribed, within one hour of the prescribed time, and with triple verification of the right resident, medication, dosage, time, and route, which was not followed in this instance.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to provide therapeutic diets as ordered by the physician for two residents. Resident R4, who has a complex medical history including severe protein-calorie malnutrition and other serious conditions, did not receive the prescribed double protein portions at lunch for eight days after the order was issued. The Dietary Manager was unaware of the physician's order and only planned to start the double portions the day after the surveyor's observation. This indicates a lack of communication and adherence to dietary orders within the facility's dietary department. Resident R2, who is severely cognitively impaired and has a history of morbid obesity and thyroid cancer, did not receive the prescribed super cereal at breakfast and ice cream at lunch and dinner as per the physician's orders. On multiple occasions, the dietary staff failed to provide the correct items, and the Dietary Manager admitted that the resident's diet should be individualized and provided as ordered. The failure to provide the correct diet items was attributed to either unavailability or oversight by the staff, but no specific reasons were documented for the omissions. The facility's policy on therapeutic diets states that diets should be prescribed by the attending physician and tailored to the resident's treatment goals and preferences. However, the observations and interviews revealed that the facility did not consistently follow these guidelines, resulting in residents not receiving the therapeutic diets as ordered. This deficiency highlights a significant lapse in the facility's dietary management and communication processes, impacting the residents' nutritional care and overall well-being.
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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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