La Bella Of Aurora
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Illinois.
- Location
- 1017 West Galena Boulevard, Aurora, Illinois 60506
- CMS Provider Number
- 145663
- Inspections on file
- 17
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at La Bella Of Aurora during CMS and state inspections, most recent first.
A cognitively intact resident with multiple medical conditions arranged for a receptionist to store her car at the receptionist’s home and allow limited personal use of the vehicle. Over several weeks, the receptionist accepted $1,490 from the resident via an electronic payment app, stating that part of the money paid for release of the resident’s car from impound after the receptionist received a speeding ticket while driving it, and the rest was for car storage. The resident recalled only smaller payments for car cleaning, gas, and a holiday gift, denied paying for storage, and later noticed suspicious bank card transactions in the same city as the facility. The administrator and social worker knew the receptionist was storing the car but were unaware of the payments. This conduct violated facility policies prohibiting staff from accepting money or electronic payments from residents and led the resident to feel terrible and bothered that her hard-earned money may have been taken without her consent.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
Staff failed to initiate CPR, call a code blue, or contact EMS for a resident with full code status who was found unresponsive. The resident was not assessed for clinical death or rigor mortis, and staff were unaware of code status and emergency procedures, resulting in Immediate Jeopardy due to noncompliance with facility policy and standards of practice.
The facility did not have a full-time RN serving as DON for an extended period after the previous DON resigned and stopped reporting to work. During this time, a corporate nurse visited only once a week, and no full-time DON was present to coordinate nursing care. This resulted in deficiencies in ADL care, urinary catheter care, IV care, oxygen therapy, medication management, infection control, and care planning for all residents.
Surveyors found that kitchen staff failed to maintain sanitary conditions, with grime and debris on food contact surfaces, improper storage of utensils and the ice scoop, and unresolved equipment issues. An LPN handled the ice scoop and obtained ice without hand hygiene or gloves, and hot foods were served below required temperatures until prompted to reheat, all contrary to facility policy.
The facility did not maintain complete infection surveillance records, failed to ensure staff used required PPE such as gowns during high-contact care for a resident on Enhanced Barrier Precautions, and did not enforce proper hand hygiene among nursing staff during medication administration and resident care. These deficiencies were observed across multiple staff and affected all residents in the facility.
The facility did not maintain complete Antibiotic Surveillance Logs and failed to evaluate infections using standardized criteria, as required by policy. Logs for multiple months were missing key information such as diagnosis, ordering practitioner, and documentation supporting necessity. The assigned Infection Preventionist was untrained and unavailable, and there was no evidence of required education or meeting records for antibiotic stewardship. This deficiency affected all residents in the facility.
The facility did not have a qualified IP with specialized infection control training after the previous DON left, and assigned the role to an MDS Nurse without the required training. Infection control surveillance tracking was incomplete for several months, and no infection control in-service training was provided to staff in the current year, contrary to facility policy.
Four residents with complex medical needs did not have comprehensive care plans addressing their individual requirements, including wound care, oxygen therapy, catheter care, and diabetes management. Observations and record reviews showed that care plans lacked measurable objectives and did not reflect physician orders or the residents' current conditions, contrary to facility policy.
Staff failed to accurately document and account for controlled medications, with discrepancies found between the number of tablets in blister packs and the amounts recorded on controlled drug forms. In one case, a blister pack had broken seals, and in several cases, medications were administered but not immediately signed out by an LPN, contrary to facility policy.
Surveyors found that several medications, including inhalers and insulin, were opened and not labeled with the date of first use, contrary to manufacturer and pharmacy guidelines. A nurse confirmed that these medications should have been dated to determine expiration.
The facility did not ensure that residents' POLST forms and physician orders were consistent, resulting in conflicting information about code status for several residents. In multiple cases, residents had signed DNR orders on their POLST forms, but their physician orders or care plans indicated full code status or lacked corresponding orders. Staff interviews revealed confusion and inconsistent processes for verifying code status in the EMR, leading to discrepancies in honoring residents' treatment wishes.
Three residents who required staff assistance for ADLs, including personal hygiene and grooming, were observed with unaddressed needs such as dirty fingernails and unshaven facial hair. Despite documented care plans and residents' requests for help, staff did not provide necessary grooming care or document refusals, resulting in unmet hygiene needs.
A nurse failed to further assess and document a change in a resident's breathing, and did not notify the physician as required by facility policy. The resident had multiple complex medical conditions and was observed making coughing-type noises while breathing, but no additional assessment or physician notification occurred.
A resident with a history of UTI and requiring toileting assistance was observed with an unsecured indwelling urinary catheter. During care, CNAs did not secure the catheter tubing or use a security device, and staff interviews confirmed that the catheter should have been anchored to prevent pulling and dislodgement.
A resident with significant weight loss and multiple medical conditions did not receive double protein portions as ordered by the physician, due to a lack of communication between nursing and dietary staff and the absence of a policy for notifying dietary of diet order changes. The resident consistently received only single portions at meals, despite ongoing weight loss and requests for more food.
A resident receiving IV antibiotics for osteomyelitis had a midline catheter dressing that was soiled and did not allow for visibility of the insertion site, preventing proper assessment and measurement. The dressing was not changed as ordered, and required documentation of site assessments and measurements was incomplete or inaccurate.
Two residents receiving oxygen therapy did not have their physician's orders for oxygen administration followed, and the facility failed to change and label oxygen and nebulizer tubing as required by policy. One resident received oxygen at a higher rate than ordered and lacked documentation of weekly tubing changes, while another reported tubing had not been changed in over a week and lacked proper labeling.
Two residents did not have pharmacy medication regimen review (MRR) recommendations addressed by facility staff or physicians. For one, recommendations regarding the ongoing use of scheduled guaifenesin and an as-needed psychotropic were not reviewed or documented, and for another, recommendations for lab monitoring and vitamin D supplementation were not acted upon. Required documentation and sign-off were missing, and staff responsible for handling these recommendations were unavailable.
Two residents with dysphagia and orders for thickened liquids were served ice cream and a nutrition shake that did not meet their prescribed consistency requirements. Staff provided these items despite care plans and facility policy specifying the need for nectar or honey thick liquids, and the speech language pathologist confirmed that the items given were not appropriate for the residents' dietary needs.
Two residents' room refrigerators were found to lack temperature monitoring, required thermometers, and proper labeling of stored foods, with staff interviews revealing confusion about responsibility for daily checks. Facility policy requiring daily temperature logs and labeling of prepared foods was not followed.
The facility failed to follow proper food storage and thawing procedures and did not maintain food service areas in a clean and sanitary manner. Observations included debris on the dish machine conveyor belt, smears and rust in the freezer, improperly stored and undated food items, and a dusty ice maker screen. The kitchen floor was also covered in dust and debris.
The facility failed to provide necessary splints and supportive equipment to two residents with hemiplegia and hemiparesis, resulting in a lack of treatment to maintain or improve their range of motion. Both residents were observed without the required devices, and recommendations for appropriate splints were made only after screenings by an occupational therapist.
The facility failed to implement fall interventions for a high-risk resident (R41) with hemiplegia, dementia, and other conditions. Despite a care plan requiring chair and bed alarms, these were not consistently used, leading to multiple falls, including a hip fracture. The facility's Fall Prevention Program policy was not adequately followed.
A resident with chronic respiratory conditions was observed using continuous oxygen without a physician's order, and the humidifier bottle was empty. The oxygen tubing and humidifier bottle were not labeled, and the nebulization mask was left uncovered, posing a risk of contamination. The Director of Nursing confirmed these deficiencies, which are against the facility's policy on oxygen administration.
The facility failed to maintain intact blister packs for controlled medications, compromising their safe and effective use. Observations revealed that blister packs of Lorazepam for three residents had broken seals that were taped over, contrary to facility policy. The DON confirmed that tampered packs should be destroyed to prevent drug theft and ensure medication safety.
The facility failed to ensure that a resident received a monthly medication regimen review (MRR) by a licensed pharmacist. The resident, with multiple medical diagnoses and on psychotropic medications, had no MRRs completed as required by the facility's policy. The Director of Nursing confirmed the absence of MRRs for the resident.
Failure to Prevent Staff Financial Exploitation of a Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from financial exploitation and misappropriation of funds by a staff member. The resident had multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus without complications, generalized muscle weakness, unspecified lack of coordination, and anxiety disorder, and was assessed as cognitively intact on a recent MDS. After a car accident and admission to the facility, the resident arranged for the facility receptionist to store her car at the receptionist’s home, with the understanding that the receptionist could use the car for personal errands. The resident later noticed suspicious transactions on her bank statements showing use of her bank card in the same city as the facility and reported that she did not recognize the charges. During interviews, the receptionist admitted that from January through February she received a total of $1,490 from the resident via a phone-based electronic payment application. The receptionist described that the resident would state she wanted to give money for storing the car, and the resident would enter the amount and tap her credit card on the receptionist’s phone to complete the transaction. The receptionist stated that $500 of this amount was used to pay for the release of the resident’s car from impound after the receptionist received a speeding ticket while driving the car, and that the remaining $990 was given randomly as payment for storing the car. The receptionist also stated she did not know she was prohibited from receiving money or financial compensation from residents. In contrast, the resident recalled giving the receptionist money for cleaning the car, gas on at least two occasions, and some money around Christmas, all sent through the phone, but denied paying for car storage. The resident expressed suspicion that the receptionist might be using her bank card but could not be certain. The administrator and social worker both acknowledged knowing that the receptionist was storing the resident’s car but denied knowing that the receptionist was receiving money from the resident or that the resident paid for the car’s release from impound due to the receptionist’s speeding ticket. Facility policies in effect prohibited abuse, exploitation, and misappropriation of resident property and specifically barred staff from requesting, borrowing, soliciting, or accepting money, gifts, or electronic payments from residents. The resident stated she felt terrible and bothered at the thought that someone from the facility might be taking her hard-earned money without her consent and that she might lose sleep over it.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Initiate CPR and Emergency Response for Full Code Resident
Penalty
Summary
Facility staff failed to perform CPR according to standards of practice, did not call a code blue, and did not contact emergency medical services (911) for a resident who was identified as full code on physician orders and in accordance with facility policy. The resident, who had a history of right femur fracture, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea, and cerebral infarction, was admitted for rehabilitation and was documented as a full code. The resident was found unresponsive, without a pulse, and cool to the touch by a registered nurse, who did not immediately initiate CPR, did not bring the crash cart, and did not use the intercom system to announce a code blue. The nurse was unaware of the resident's code status at the time and sought guidance from a former DON by phone, who instructed her to stop compressions and not to call 911. No assessment for clinical death or rigor mortis was documented. Other staff present during the incident also failed to take appropriate action. An LPN responded to a call for assistance but did not assess the resident, did not call a code blue, did not bring the crash cart, and did not call 911. A CNA entered the room to assist with cleaning the resident but did not initiate emergency procedures or call for help. Staff interviews revealed a lack of knowledge regarding code blue procedures, use of the intercom system, and the process for pronouncing death. The facility did not have a policy regarding nurses determining or pronouncing death, and there was no investigation conducted regarding the resident's death at the time. The facility's policy required immediate action in medical emergencies, including initiation of CPR, announcement of code blue, and calling 911 for residents with full code status. However, these procedures were not followed for the resident in question. The deficiency was identified as Immediate Jeopardy, affecting multiple residents with full code status, due to the failure to provide basic life support and follow established emergency protocols.
Removal Plan
- Administrator/designee will provide training for all staff on Medical Emergency Response and CPR policy. This includes the employee who first witnesses or is first on the site of a medical emergency will initiate immediate action. The training also includes if a resident experiences cardiac arrest or unresponsiveness, the facility staff will provide basic life support including CPR, prior to the arrival of emergency medical services in accordance with the resident's advanced directives. The training will continue until all staff have attended. Agency staff and staff who missed the training will receive training prior to working their next scheduled shift.
- Administrator/designee will provide training for all staff on Resident Rights regarding Treatment and Advance Directives.
- Provide Mock Code evaluation drills in a Mandatory Meeting and continue until all staff have attended a drill. The Mock Code Blue Audit tool will be used during the drill as a guide for staff roles and tasks during a Code Blue. The Administrator/designee will provide the training. The training will continue until all staff have been trained.
- The Maintenance Director will provide training on the use of the intercom system, to announce Code Blue on the overhead page, to all staff, as part of the Mock Code evaluation drills. The training will continue until all staff have been trained.
- The facility developed a process to determine if a resident has executed an advance directive. The Social Service Director reviewed Advance Directive with the residents, and the process is ongoing.
- Upon admission, the Nurse will ensure a resident with an advance directive, will communicate the resident's choice to the Health Care Practitioner and obtain the order, and provide a copy of the Advanced Directive to Social Services/designee, and ongoing.
- The Facility Quality Assurance Committee (Administrator, Regional Director of Operations, Regional Clinical Director and Medical Director) met to review the F678 IJ (Immediate Jeopardy).
- The Facility created a Quality Assurance audit tool to be used by the DON (Director of Nursing)/Designee, for all Licensed Nurses, for Medical Emergency Response. The Audit will be done with every nurse and then twice weekly with random nurses. The results of the Audits will be reviewed with the QA (Quality Assurance) Committee at their monthly meetings.
- The Facility created a QA audit tool to be used by Social Service/designee to assess all new admissions and readmissions for Code Status and or POLST orders, care plan and update the list of resident code status. The audit tool will be done daily, then monthly and then quarterly.
Failure to Maintain Full-Time DON Results in Multiple Care Deficiencies
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was assigned to serve as a full-time Director of Nursing (DON) to coordinate nursing care and supervision for all 52 residents. According to the facility's records and staff interviews, the designated DON resigned and did not return to work after April 4, 2025, despite initially stating her resignation would be effective May 2, 2025. The facility did not receive an official resignation letter, and the DON did not perform her duties from April 4 onward. During this period, a corporate nurse visited only once a week, and there was no full-time RN serving as DON until a new DON was hired to start on April 22, 2025. During the survey conducted from April 15 through April 18, 2025, it was observed that the absence of a full-time DON led to deficiencies in several areas, including activities of daily living (ADL) care, urinary catheter care, intravenous (IV) care, oxygen therapy and care, medication labeling, controlled medication inventory and storage, addressing pharmacy recommendations, infection control surveillance, advance directives, and care plan development. These deficiencies affected all residents in the facility during the period without a full-time DON.
Failure to Maintain Sanitary Kitchen Practices and Food Safety Standards
Penalty
Summary
Surveyors observed multiple unsanitary practices in the facility kitchen affecting all 52 residents who received food prepared there. The hand sink area was found to be soiled with unknown grime and contained used scrub pads, which were reportedly used for prewashing dishes due to limited space. The kitchen's two-door steel refrigerator had visible grime and smears on its handle and surface, and a pan of stagnant water was placed inside to catch drips from an unresolved leak that had been previously identified in the last annual survey. Additional observations included a prep station drawer and shelves beneath a workstation that stored cooking utensils and pans, all of which had accumulated dust, food debris, and grime. The ice scoop was stored on a dusty workstation with unknown debris, and staff were unclear about proper storage procedures for the scoop. Further, an LPN was seen entering the kitchen, taking the ice scoop from the unclean workstation, and using it to get ice for a water pitcher without washing hands or wearing gloves. During meal service, the cook was prompted to check food temperatures, revealing that pureed spaghetti and garlic bread were below the required 135 degrees Fahrenheit, necessitating reheating. The facility's own policies require clean and sanitized storage of utensils and equipment, proper handling and storage of ice and scoops, and monitoring of food temperatures to prevent foodborne illness, all of which were not followed as observed during the survey.
Infection Control Deficiencies: Incomplete Surveillance, Improper PPE, and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as evidenced by incomplete infection surveillance, improper use of personal protective equipment (PPE), and inadequate hand hygiene practices among staff. The infection surveillance logs for January, February, and March 2025 were missing critical data such as infection site, organism, lab/culture results, symptoms, isolation/precautions, and whether infections were acquired in the facility. Additionally, there was no infection surveillance conducted for April 2025, and the designated Infection Preventionist had not received appropriate training. During direct care, staff did not adhere to Enhanced Barrier Precautions (EBP) for a resident with multiple medical diagnoses, including paraplegia and a urinary tract infection, who had an indwelling urinary catheter and intravenous catheter. Certified Nursing Assistants provided high-contact care activities such as peri-care, catheter care, and transfers without wearing required isolation gowns, although they did change gloves and sanitize hands between tasks. Nursing staff also failed to perform proper hand hygiene during medication administration and resident assessments. One nurse wore the same gloves while performing multiple tasks, including blood glucose checks and handling the medication cart, without changing gloves or performing hand hygiene. Another nurse moved between residents and tasks, such as adjusting oxygen tubing, checking blood glucose, and administering medications, without performing hand hygiene between residents or tasks. These actions were inconsistent with the facility's hand hygiene policy, which requires hand hygiene before and after resident care, between tasks, and between residents, regardless of glove use.
Incomplete Antibiotic Surveillance and Lack of Infection Evaluation
Penalty
Summary
The facility failed to maintain complete documentation on its Antibiotic Surveillance Log and did not evaluate the presence of infection using standardized criteria as required by its own policy. The Antibiotic Surveillance Logs for January, February, and March were incomplete, with missing information such as diagnosis for antibiotic use, ordering practitioner, documentation supporting necessity, and whether the antibiotic was ordered upon admission. For example, in January, 4 out of 11 residents lacked a diagnosis for antibiotic use, and 10 out of 11 had missing data in key columns. Similar patterns of incomplete documentation were observed in the logs for February and March. Additionally, there was no Antibiotic Surveillance Log available for April, and the staff member assigned as Infection Preventionist was not trained and unavailable for interview. The facility was unable to provide completed assessment forms that defined infections using recognized criteria such as McGeer, Loeb's Minimum, or NHSN surveillance definitions. Furthermore, there were no records of antibiotic stewardship meeting minutes or documentation of education provided to physicians, staff, residents, or families, as outlined in the facility's policy. This deficiency applied to all 52 residents in the facility, indicating a systemic failure to implement and monitor the antibiotic stewardship program as required.
Failure to Designate Qualified Infection Preventionist and Maintain Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was designated and responsible for the infection prevention and control program. The previous IP, who was the Director of Nursing, left the facility on April 4, 2025, and the duties were assigned to the MDS Nurse, who had not completed specialized training in infection prevention and control. The Administrator confirmed that there was no staff member onsite who had completed the required specialized training in infection control at the time of the survey. Additionally, infection control surveillance tracking provided for January, February, and March 2025 was found to be incomplete, and there was no tracking available for April 2025. The most recent infection control in-service training for staff was conducted in December 2024, with no further training provided in 2025. The facility's policy requires the IP to lead surveillance activities, maintain documentation, and report findings, but these responsibilities were not being fulfilled due to the lack of a qualified IP and incomplete surveillance documentation.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the individualized needs of four residents, as identified through observation, interview, and record review. One resident with multiple diagnoses, including diabetes and a stage 3 pressure ulcer, did not have a care plan addressing the pressure ulcer or its prevention, despite ongoing wound care and physician orders for barrier cream. Another resident receiving continuous oxygen therapy for acute respiratory failure and chronic obstructive pulmonary disease lacked a care plan for oxygen administration or management of respiratory conditions, even though physician orders specified oxygen requirements and the resident was observed using oxygen. A third resident with a urinary catheter and moderate cognitive impairment required assistance with grooming and hygiene but had no care plan addressing ADL support or catheter care. Observations revealed the resident's catheter was not secured, and nail and facial hair care were not provided, despite the resident's cooperation during care. Staff did not offer or document grooming services, and the care plan did not reflect these needs. The fourth resident, admitted for wound care following a partial foot amputation due to diabetic complications, had no care plan addressing diabetes management or wound care, even though the resident was observed with a wound dressing and ambulating independently. Facility policy requires that comprehensive, person-centered care plans be developed within seven days of completing the MDS assessment, addressing all identified needs and services. However, the care plans for these residents did not include measurable objectives or timeframes for their specific medical, nursing, and psychosocial needs, as required by professional standards and facility policy.
Failure to Accurately Account for and Store Controlled Medications
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications and did not maintain proper storage of narcotic medications in sealed packaging. During a medication count with a nurse, it was observed that one resident's blister pack of Tramadol had broken seals on two tablets. For three other residents, the number of controlled medication tablets remaining in their blister packs did not match the amounts recorded on the controlled drug receipt/record/disposition forms. In each case, the nurse stated that the medication had been administered but not yet signed out on the required documentation. The facility's policy requires that controlled medications be documented in the Medication Administration Record and signed out on the controlled drug record immediately after administration. Additionally, any controlled medication with a broken seal should be disposed of with a witness to prevent discrepancies or diversion. These requirements were not followed, resulting in discrepancies between the physical count of medications and the documentation, as well as improper storage of controlled substances.
Failure to Date Opened Medications for Expiration
Penalty
Summary
Surveyors observed that multiple medications in the facility were not labeled with the date they were opened, as required to determine their expiration dates. Specifically, an inspection of the medication cart revealed that Incruse Ellipta and Fluticasone Furoate/Vilanterol Ellipta inhalers, as well as Insulin Lispro and Insulin Lantus, were opened but not dated. Manufacturer and pharmacy guidelines for these medications require dating upon opening to ensure proper disposal after a specified period. A corporate nurse confirmed that these medications should have been dated when first opened.
Inconsistent Documentation of Advance Directives and Code Status Orders
Penalty
Summary
The facility failed to ensure that residents' advance directives, specifically their POLST forms and physician orders, were consistent and accurately reflected their treatment wishes in the event of a medical emergency. In three cases, residents had signed POLST forms indicating Do Not Attempt Resuscitation (DNR), but their physician orders and care plans either indicated full code status or did not have corresponding orders, resulting in conflicting information about their code status. For example, one resident with multiple diagnoses, including end-stage renal disease and a kidney transplant, was cognitively intact and had a signed POLST indicating DNR, but the active physician order and care plan listed the resident as full code, instructing staff to attempt resuscitation. Staff interviews revealed confusion and reliance on different sources within the electronic medical record (EMR) to determine code status. LPNs reported checking the EMR dashboard and active orders, but these did not always match the signed POLST forms. In one instance, a nurse acknowledged the conflicting information between the dashboard, active order, and POLST, and another nurse was unable to locate the POLST in the EMR due to unfamiliarity with the system. The facility's process involved social services uploading POLST forms and updating care plans, but only nursing staff entered orders, leading to gaps in communication and documentation. The facility's policy required that advance directives be reviewed upon admission, communicated to staff, and periodically reviewed during care planning. However, in these cases, the policy was not followed, resulting in discrepancies between residents' documented wishes and the orders available to staff during emergencies. This failure to ensure consistency and proper communication of advance directives affected multiple residents and was confirmed through record review and staff interviews.
Failure to Provide Grooming and Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene assistance to residents who required help with activities of daily living (ADLs). One resident was observed in the dining room with black and brown substances under her fingernails, brownish discoloration of the nail beds, and curly facial hair on her chin. Despite being pleasant and cooperative during peri-care and catheter care, staff did not offer nail care or shaving, and there was no documentation of refusal or a care plan indicating non-compliance. The resident's Minimum Data Set (MDS) indicated a need for assistance with personal hygiene. Two additional residents, both with significant physical or cognitive limitations, were observed with long, unshaven facial hair and both expressed a need and desire for staff assistance with shaving. One had contractures in both hands and was moderately cognitively impaired, while the other was legally blind and required total assistance for personal hygiene. Both residents' care plans documented their dependence on staff for ADLs, yet staff failed to provide the necessary grooming assistance as observed and confirmed by interviews.
Failure to Assess and Notify Physician After Change in Resident's Breathing
Penalty
Summary
A deficiency occurred when a nurse failed to further assess a resident after observing a change in breathing during an overnight shift. The resident, who had multiple diagnoses including a right femur fracture, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea, and a history of cerebral infarction, was noted to be making coughing-type noises while breathing during rounds. Despite this observed change, the nurse did not conduct a further assessment or document the observation in the resident's progress notes. Additionally, the resident's physician was not notified of the change in condition, which was contrary to the facility's policy requiring physician notification and documentation when there is a change in a resident's status that may require new treatment.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
A deficiency was identified when a resident with a history of urinary tract infection and requiring assistance with toileting and hygiene was observed with an unsecured indwelling urinary catheter. During multiple observations, the resident was seen in a wheelchair with the catheter bag hanging under the seat and the catheter tubing hanging loosely, without any securing device in place. Certified Nursing Assistants providing peri-care and catheter care did not secure the catheter or apply a security device. Interviews with nursing staff confirmed that the catheter should have been secured to prevent pulling, dislodgement, and to ensure proper placement.
Failure to Provide Double Protein Portions for Resident with Weight Loss
Penalty
Summary
A deficiency occurred when a resident with a history of significant weight loss and multiple medical conditions, including hemiplegia, aphasia, end-stage heart failure, chronic kidney disease, and metastatic prostate cancer, did not receive double portions of protein as ordered by the physician. The resident's diet order specified a general diet with mechanical soft texture, regular/thin consistency, and double proteins at each meal, along with super cereal at breakfast. Despite this, the resident consistently received only single portions of protein at meals, as confirmed by both the resident and direct observation during meal service. The diet card and dietary spreadsheet reflected only a single portion, and the dietary manager was unaware of the double protein order. Interviews revealed that the dietitian had recommended super cereal but was not involved in the double protein order, which originated from nursing and was documented in the physician order sheet. The regional director of operations confirmed that the facility lacked a policy or procedure for notifying dietary staff of diet order changes. The resident's care plan included interventions to provide diet and supplements as ordered, but these were not implemented, resulting in the resident not receiving the prescribed nutritional support despite ongoing weight loss and expressed requests for additional food.
Failure to Maintain Visible and Clean IV Dressing for Resident with Midline Catheter
Penalty
Summary
A deficiency was identified when a resident receiving intravenous (IV) antibiotics for osteomyelitis was found to have a midline catheter dressing that did not allow for proper assessment of the insertion site. The dressing consisted of gauze, which was soiled with dry blood, covered by a transparent dressing that was stained, wrinkled, and loose at the edges. The insertion site was not visible for assessment, and the dressing had not been changed in accordance with physician orders, which specified weekly changes and as needed if soiled. The resident was unable to recall when the dressing was last changed, and observations over multiple days confirmed the dressing remained unchanged and soiled. Nursing staff reported difficulty in accurately measuring the IV line and arm circumference due to the non-visible insertion site, despite documentation requirements to record these measurements every shift. The Medication Administration Record (MAR) showed inconsistent or missing documentation for arm circumference and dressing changes. The resident's care plan required regular assessment of the IV site for signs of infection or complications, but the site was not visible due to the dressing method used. These actions and inactions resulted in the failure to ensure the safe and appropriate administration of IV fluids and proper monitoring of the IV site.
Failure to Follow Oxygen Therapy Orders and Tubing Change Protocols
Penalty
Summary
The facility failed to follow physician orders for oxygen administration and did not ensure that oxygen and nebulizer tubing were changed and labeled according to facility policy for two residents. One resident with COPD and chronic respiratory failure was observed receiving oxygen at a rate higher than the physician's order, and the oxygen tubing and humidifier bottle were not labeled to indicate when they were last changed. The resident's care plan required weekly changing and labeling of the oxygen tubing, but there was no documentation in the medical or treatment records to show this was done. A registered nurse adjusted the oxygen flow to the correct rate during the observation, and the corporate nurse confirmed that both the physician's order and care plan interventions should have been followed. Another resident with acute respiratory failure and COPD was found receiving oxygen at the ordered rate, but reported that the nasal cannula had not been changed in at least two weeks and the nebulizer tubing had not been changed in over a week. Neither the nasal cannula nor the nebulizer tubing were labeled with the date of last change. Facility policy required weekly changing and labeling of oxygen tubing and changing nebulizer tubing every 72 hours or as needed, but these procedures were not followed for either resident.
Failure to Address Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to address pharmacy medication regimen review (MRR) recommendations for two residents reviewed for unnecessary medications. For one resident with multiple chronic conditions, including COPD, heart failure, and morbid obesity, the pharmacist repeatedly recommended reviewing the continued need for scheduled guaifenesin and the appropriateness of a long-standing as-needed lorazepam order. Despite these recommendations, there was no documentation that the physician or facility staff reviewed or acted upon them, and the resident continued to receive guaifenesin as scheduled, while lorazepam had not been administered for several months. For another resident with vascular dementia, schizoaffective disorder, and other neurological conditions, the pharmacist recommended assessing the need for a valproic acid level and considering vitamin D supplementation due to a low lab value. The MRR forms for this resident were not signed off by the attending physician, and there was no documentation that the recommendations were reviewed or addressed. Interviews confirmed that the staff member responsible for receiving pharmacy recommendations was unavailable, and the facility's policy required staff to act upon all MRR recommendations, which was not followed in these cases.
Failure to Provide Properly Modified Diet Consistencies for Residents on Thickened Liquids
Penalty
Summary
The facility failed to provide appropriate modified diet consistencies for two residents who required thickened liquids due to their medical conditions. One resident with diagnoses including Parkinson's disease, dementia, and dysphagia was ordered a pureed diet with nectar thickened liquids, but was observed receiving a bowl of ice cream along with their meal. The resident's meal ticket and care plan both indicated the need for pureed texture and nectar thick liquids, yet the inclusion of ice cream did not meet these requirements. Another resident with a history of cerebral infarction, hemiplegia, vascular dementia, and oropharyngeal dysphagia was ordered a pureed diet with honey thick liquids. This resident was also observed receiving a bowl of ice cream and a nutrition shake (mighty shake) that was not at the required honey thick consistency. The dietary manager stated that ice cream was considered thick and that the shake was already thickened, but the speech language pathologist clarified that ice cream melts to a thin liquid and that the mighty shake was only nectar thick, not honey thick. Facility policy also specified that items like ice cream and shakes that change consistency at room or body temperature are not appropriate for residents on thickened liquids.
Failure to Maintain Safe and Sanitary Resident Refrigerators
Penalty
Summary
The facility failed to maintain resident room refrigerators in a safe and sanitary manner for two residents reviewed for personal food storage. During observations, one resident's refrigerator contained multiple food items, including prepared foods in unlabeled containers, cartons of milk, and other perishable items, none of which were labeled with dates as required by facility policy. Additionally, neither refrigerator had a thermometer inside, and there were no temperature logs present. The resident stated that her family brings the food, but there was no indication that the food was being monitored for safety or compliance with the facility's policy. Interviews with facility staff revealed a lack of clarity regarding responsibility for monitoring the refrigerators. A CNA was unsure who was responsible for checking the refrigerators, while the Housekeeping Director stated that refrigerators are checked only once a month for expired items and cleaned at that time, but temperatures are not monitored. Facility policies require that all prepared foods be labeled and dated, consumed within three days, and that refrigerator temperatures be logged daily and maintained at or below 41 degrees Fahrenheit. These procedures were not being followed, resulting in the deficiency.
Failure to Maintain Sanitary Food Storage and Preparation Areas
Penalty
Summary
The facility failed to follow proper food storage and thawing procedures and did not maintain food service areas in a clean and sanitary manner. During an initial tour of the kitchen, a cook was observed unloading cleaned dishes onto a conveyor belt with unidentifiable debris and food particles. The reach-in freezer had unknown smears, rust, and extensive blackish substance and debris on the inside compartments and racks. Multiple open and undated hamburger patties were stored improperly, and a half-drunk chocolate milkshake was found on the top shelf. The reach-in refrigerator had smears, dust, and a wobbling door, with a large pan collecting water from a leaking condenser. Inside, there were improperly stored and undated deli meats. Additionally, raw frozen meat was improperly thawing in a 3-compartment sink without running water, and the ice maker screen was covered with extensive dust, blowing into the food prep area. The kitchen floor under the stove and shelving was covered in dust and unknown debris. A follow-up visit revealed that the freezer still had extensive blackish substance on the shelving and side compartments, with undated packages of diced chicken and ravioli. The refrigerator continued to have a large pan of water collecting on the top shelf, with unidentifiable streaks, smears, and dust on the outside panel and door handles. The ice maker screen remained dusty, and the floor under the stove and prep areas was still covered in dust and unknown debris. The dietary manager acknowledged that all items placed in the freezer or refrigerators should have been labeled and dated and that the kitchen is cleaned daily and deep cleaned weekly. Facility policies on sanitation and food safety were not adhered to, leading to these deficiencies.
Failure to Provide Necessary Splints and Supportive Equipment
Penalty
Summary
The facility failed to provide treatment and services to increase range of motion and prevent a further decrease in range of motion for two residents. Resident 26, who has hemiplegia and hemiparesis following a cerebral infarction, was observed without a splint despite having left side weakness and a history of using a splint at a previous facility. The resident had not been provided a splint since admission to the current facility. An occupational therapist later recommended a hand splint for Resident 26 after a screening was conducted at the request of the Director of Nursing. Resident 43, who also has hemiplegia and hemiparesis following a cerebral infarction, was observed without a splint or supportive device for his right hand and arm, despite having functional limitations in range of motion. The resident's mother provided a splint, which the resident found comfortable. An occupational therapist screened Resident 43 and recommended a right hand splint and right arm sling to prevent contracture and for proper positioning. The therapist also suggested discontinuing the use of a previously ordered pool noodle splint at night in favor of the new devices.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to have fall interventions in place for a resident (R41) who was at high risk for falls. R41, diagnosed with hemiplegia, hemiparesis, dementia, and other conditions, was observed without a chair alarm on multiple occasions despite being assessed as a high fall risk. Interviews with staff revealed that R41 had a history of falls, including a significant fall resulting in a hip fracture. The MDS Coordinator (V4) confirmed that R41 should have had a chair and bed alarm as part of his fall prevention care plan, but these interventions were not consistently implemented. The chair alarm was found in R41's closet instead of being used as intended. R41's care plan documented several falls with various interventions, including reminders to place sandals out of the walking path and supervision during weight-bearing activities. Despite these documented interventions, the facility's failure to consistently use the chair and bed alarms as specified in the care plan contributed to the deficiency. The facility's Fall Prevention Program policy required individualized care and services to minimize fall risks, but the lack of adherence to these protocols for R41 indicates a lapse in following the established guidelines.
Failure to Obtain Physician's Order and Properly Manage Oxygen Administration
Penalty
Summary
The facility failed to ensure that a physician's order was obtained for the administration of oxygen for a resident with chronic obstructive pulmonary disease and acute and chronic respiratory failure. The resident was observed using continuous oxygen via nasal cannula without a physician's order, and the humidifier bottle attached to the oxygen concentrator was empty. Additionally, the oxygen nasal cannula tubing and humidifier bottle were not labeled, and the nebulization mask was left uncovered on the bedside table, posing a risk of contamination. The resident reported dry nostrils due to the empty humidifier bottle, and staff were unaware of when the nasal cannula tubing and humidifier bottle were last changed. The Director of Nursing confirmed that there should be a physician's order for oxygen use and that the humidifier bottle should not be empty when the oxygen concentrator is running. The Director also acknowledged that the oxygen nasal cannula tubing and humidifier bottle should be labeled, and the nebulization mask should be covered when not in use to prevent contamination. The facility's policy on oxygen administration requires a physician's order, proper labeling, and regular changing of humidifier bottles and nebulizer tubing to ensure infection control and proper respiratory care.
Failure to Maintain Intact Blister Packs for Controlled Medications
Penalty
Summary
The facility failed to ensure that blister packs containing controlled medications were maintained intact, compromising the safe and effective use of these medications. During an observation of medication cart #2, it was found that a blister pack of Lorazepam 2 mg for one resident had 28 intact tablets and one additional tablet with a broken seal that was taped over. Similarly, another resident's blister pack of Lorazepam 1 mg had 29 intact tablets and one additional tablet with a broken seal that was taped over. The registered nurse present during the observation was unaware of who had taped the blister packs. In another instance, during an observation of medication cart #1, a blister pack of Lorazepam 1 mg for a third resident was found to have 41 intact tablets and one additional tablet with a broken seal that was taped over. The Director of Nursing confirmed that tampering with blister packs, including taping over broken seals, is not acceptable practice and that such tampered packs should be destroyed to prevent drug theft, misappropriation, and to ensure medication safety. The facility's policies on controlled substance administration and destruction of unused drugs were not followed, as they require the destruction of any tampered blister packs.
Failure to Conduct Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a resident received a monthly medication regimen review (MRR) by a licensed pharmacist. This deficiency was identified for a 75-year-old female resident who was admitted with diagnoses including Dementia, Hypertension, Delusional Disorders, Depression, Hyperlipidemia, Osteoarthritis, and Anxiety. The resident's medication orders included Seroquel for delusional behavior and Venlafaxine Hydrochloride Extended Release for depression. A review of the resident's medical record on May 14, 2024, revealed no completed MRRs by the pharmacist. The Director of Nursing confirmed that no MRRs had been conducted for the resident, despite the facility's policy requiring monthly reviews and the resident's care plan indicating the need for pharmacy consultation.
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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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