Lakewood Nrsg & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Plainfield, Illinois.
- Location
- 14716 S Eastern Avenue, Plainfield, Illinois 60544
- CMS Provider Number
- 145761
- Inspections on file
- 22
- Latest survey
- October 24, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Lakewood Nrsg & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and an indwelling urinary catheter was not properly monitored, as staff failed to document urinary output for over 13 hours and did not assess the catheter's patency. The resident was later hospitalized with urinary retention and a UTI, and emergency room findings revealed a dry catheter and a significantly distended bladder. Staff interviews indicated inconsistent catheter care practices and lack of adherence to facility policy requiring regular output documentation and assessment.
Residents in the facility expressed fear of retaliation when voicing grievances, with reports of delayed assistance and rough handling after complaints. During a resident council meeting, multiple residents confirmed their fear of reporting issues due to potential staff retaliation, contradicting the facility's policy that ensures residents can voice grievances without fear of reprisal.
The facility failed to assist residents with personal hygiene and grooming, as observed in five residents who required help with ADLs. Despite being alert and oriented, these residents had unkempt facial hair and long, jagged fingernails, and expressed their need for staff assistance, which was not provided. Additionally, a resident with multiple health issues reported not receiving regular bed baths and had a urinal left on the tray table next to their meals. The Director of Nursing acknowledged the need for grooming and hygiene assistance during observations.
The facility failed to ensure accurate accounting and proper storage of controlled medications, affecting several residents. Discrepancies in medication counts and improper handling of narcotic packaging were observed, with nurses failing to document administration and taping over broken seals, contrary to facility policy.
The facility failed to label and manage medications properly for four residents, resulting in deficiencies in medication storage and expiration tracking. Medications were either not dated upon opening or not removed after their use-by date, as observed during an inspection. The DON confirmed that staff must date all medications upon opening to comply with guidelines.
The facility did not follow the menu extension sheet for mechanical soft and pureed diets, resulting in incorrect portion sizes for six residents. The dietary manager was unaware of the correct portions, and the dietitian later confirmed the discrepancies. This affected the dietary service process for residents requiring specific diet consistencies.
The facility failed to follow infection control practices, including leaving a urinal on a resident's tray table during meals, therapists not wearing PPE for a resident on Enhanced Barrier Precautions, and nurses using contaminated syringes and handling medications with bare hands. These actions indicate non-compliance with infection control protocols.
The facility failed to maintain a functioning electronic monitoring alarm system for residents at high risk for elopement. During an observation, a resident with an electronic monitoring device approached the main exit door, but the alarm did not activate due to a power issue with the control panel. Four residents with cognitive impairments and high elopement risk were affected, highlighting a lapse in the facility's protocol for daily checks of these safety devices.
A facility failed to update the smoking assessment and care plan for a resident who resumed smoking. Despite the resident's cognitive intactness and history of serious health conditions, the facility did not conduct a current smoking assessment or revise the care plan, as required by policy. Staff interviews revealed a lack of awareness about the resident's smoking status, and the resident was observed smoking with the assistance of a hospice volunteer and nursing staff.
A resident with severe cognitive impairment and Alzheimer's disease was found with overgrown and misaligned toenails, indicating a failure in providing necessary foot care. The facility's LPN and DON acknowledged the need for regular assessment and podiatry consults, which were not conducted as per the facility's policy.
A facility failed to follow a physician's order for oxygen administration for a resident with respiratory issues, providing one liter per minute instead of the prescribed two liters. Additionally, the facility did not maintain the oxygen equipment as per policy, with outdated tubing and an empty humidifier bottle, which was acknowledged by the DON.
A nurse administered incorrect doses of Lactulose and Novolog to a resident, resulting in a medication error rate of 7.69%, exceeding the acceptable 5% threshold. The resident was given 10 ml of Lactulose instead of 30 ml and 6 units of Novolog instead of 4 units, as per the MAR. The DON confirmed the need to follow physician orders and the facility's medication administration policy.
The facility failed to provide meal options of similar nutritive value to the main entree for two residents. During lunch, they received a grilled cheese sandwich with a side of zucchini instead of Lemon Baked Tilapia. The dietitian confirmed the substitute meal lacked sufficient protein compared to the main entree, contrary to the facility's policy on selective menus.
A resident with limited upper extremity mobility was not provided with appropriate adaptive eating equipment, leading to difficulties in eating independently. The resident, diagnosed with dementia and cerebral conditions, was observed dropping food while eating with a fork using only the right hand. Initially, no staff assistance was provided, but later assessment determined the need for a scoop plate to aid in self-feeding. The DON emphasized the importance of staff reporting such needs for timely assessment and provision.
A resident with a tracheotomy experienced severe respiratory distress due to inadequate suctioning at a facility. Despite having a history of chronic respiratory failure and requiring frequent suctioning, the resident was found struggling to breathe for up to 90 minutes before EMS intervened. The facility's disorganization and reliance on agency nurses contributed to the deficiency, as noted by EMS and the Ombudsman.
A resident with complex medical conditions experienced a decline in health, marked by lethargy and decreased oral intake. Despite instructions from the physician to closely monitor the resident, the facility failed to consistently document vital signs and neurological checks. The resident's condition worsened, leading to hospitalization with seizures and encephalopathy.
The facility failed to provide adequate personal hygiene for six residents dependent on ADL care. Observations revealed long, jagged fingernails, oily hair, and dry, flaking skin. Interviews with residents and staff confirmed inconsistent performance of personal hygiene tasks, leading to potential health risks. The facility's policy emphasized necessary care, but the observations indicated a failure to adhere to this policy.
The facility failed to update physician orders to reflect a resident's DNR status, despite the resident's POLST requesting comfort-focused treatment and allowing a natural death. Staff interviews confirmed the inconsistency, and the facility's policy on Advanced Directives was not followed.
A resident with chronic respiratory failure, type 2 diabetes, tracheostomy, and gastrostomy received medications via his G tube without the nurse verifying the tube's placement. The nurse admitted to not checking the placement, which is necessary to prevent fluids and medications from entering the lungs. The Director of Nursing confirmed that the nurse should have verified the G tube placement before administering any medications or flushes, as per the facility's policy.
The facility failed to provide adequate respiratory care for four residents requiring continuous oxygen therapy and proper storage of respiratory equipment. Observations included residents without connected oxygen supply, uncovered nebulization masks, and a BIPAP mask, posing a risk of infection and compromised respiratory health.
A resident with swallowing difficulties was given unthickened coffee and juice despite physician orders for nectar thick liquids. The error was acknowledged by the LPN and DON, but the responsible staff member was not identified. The dietician confirmed the risk of aspiration from thin liquids.
Failure to Monitor Catheter Output and Assess Urinary Status
Penalty
Summary
The facility failed to properly assess and monitor the urinary status of a resident with an indwelling urinary catheter, resulting in urinary retention and subsequent hospitalization for a urinary tract infection (UTI). The resident, who was severely cognitively impaired and had diagnoses including chronic kidney disease, benign prostatic hyperplasia, and neuromuscular dysfunction of the bladder, had an order for catheter care and for urinary output to be recorded every shift. However, documentation showed that the last recorded catheter output was at 10:30 PM on one day, with no further documentation for approximately 13 hours prior to the resident's discharge. During this period, there was no evidence that staff assessed the catheter's patency or the resident's urinary output, despite facility policy requiring output to be recorded every shift and the collection bag to be emptied at least every eight hours. When the resident was being transferred, paramedics diverted him to the hospital due to concerning vital signs and mental status. In the emergency room, the catheter was found to be dry, and the bladder was exceptionally full, with about 1.9 liters of urine drained after catheter replacement. The ER diagnosis included UTI associated with the indwelling catheter, urinary retention, and possible acute kidney injury. Interviews with staff revealed a lack of recall regarding the resident's catheter status and inconsistent practices regarding catheter assessment and documentation. The facility's own policy emphasized the need for regular monitoring and documentation of urinary output, as well as observation for signs of infection or retention, which were not followed in this case.
Residents Fear Retaliation for Voicing Grievances
Penalty
Summary
The facility failed to ensure that residents felt safe voicing grievances without fear of retaliation. This deficiency was identified through interviews and record reviews involving ten residents. Several residents expressed fear of retaliation if they reported grievances, with some stating that they had been advised by other residents not to complain about care. Specific incidents included a resident who reported that after complaining about delayed assistance, the staff's response worsened, and they experienced rough handling. Another resident mentioned being told by a CNA that they could not be changed every time they urinated, and they felt the staff were not nice when requests were made. During a resident council meeting, multiple residents expressed fear of reporting grievances due to potential retaliation by staff. They reported that retaliation included staff not answering call lights timely, not assisting with care, and being rough when providing assistance. One resident mentioned that the fear of retaliation was always present when they had concerns, and others in the meeting agreed. The facility's resident rights guidelines, revised in October 2023, state that residents have the right to voice grievances without fear of discrimination or reprisal, yet the residents' experiences contradicted this policy. The facility's failure to uphold its grievance policy and ensure a safe environment for residents to voice concerns was evident in the testimonies of the residents. The fear of retaliation was a common theme, with residents feeling that their complaints would lead to negative consequences, such as delayed assistance or rough handling. This environment of fear and intimidation prevented residents from exercising their rights to voice grievances, as outlined in the facility's resident rights guidelines.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents who required help with personal hygiene and grooming. Five residents were identified as needing assistance, yet they were observed with unkempt facial hair and long, jagged fingernails. These residents, despite being alert and oriented, expressed their desire for staff assistance, which was not provided. The Director of Nursing (V2) acknowledged the need for grooming and hygiene assistance during observations. One resident, with a diagnosis of muscle disorder, was observed with long facial hair and expressed a desire for staff to shave him. Another resident, with a displaced fracture and muscle atrophy, had long and jagged fingernails and reported asking staff for assistance multiple times without receiving help. Similarly, other residents with various diagnoses, including acute respiratory failure and multiple sclerosis, were observed with long, unkempt fingernails and expressed their need for staff assistance, which was not provided. Additionally, a resident with multiple health issues, including respiratory failure and morbid obesity, reported not receiving regular bed baths and had a urinal left on the tray table next to their meals. This resident expressed that hygienic care was not offered on non-shower days, contrary to the facility's expectations. The Director of Nursing confirmed that staff are expected to provide daily hygienic care, including shaving and nail care, as needed, but these services were not consistently provided to the residents.
Controlled Medication Handling Deficiencies
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications and proper storage of narcotic medications, affecting four out of five residents reviewed for controlled medications. On April 1, 2025, discrepancies were noted during medication counts with various nurses. For instance, a nurse failed to sign out a tablet of Tramadol administered to a resident, resulting in a discrepancy between the actual count and the record. Another nurse was found to have taped over a broken seal of a Tramadol blister pack, which is against the facility's policy. Further observations revealed that a blister pack of Lorazepam had a torn tablet, and a nurse failed to document the administration of Methylphenidate, leading to a discrepancy in the count. The Director of Nursing confirmed that nurses are required to sign out narcotic medications immediately after administration and that damaged packaging should not be taped over but discarded with a witness. The facility's policy mandates accurate accountability and documentation of controlled substances, which was not adhered to in these instances.
Medication Labeling and Expiration Tracking Deficiency
Penalty
Summary
The facility failed to properly label and manage medications for four residents, leading to deficiencies in medication storage and expiration tracking. During an inspection, it was observed that medications for residents R315, R32, R4, and R33 were either not dated upon opening or not removed after their use-by date. Specifically, R315's and R32's Trelegy Ellipta inhalers were opened but not dated, which is crucial for determining their expiration as they should be discarded six weeks after opening. R4's Fluticasone propionate/Salmeterol inhaler was opened on January 20, 2025, but not discarded by its expiration date of February 20, 2025, and R4's Incruse Ellipta was also opened without a date. Similarly, R33's Arnuity Ellipta was opened and not dated. The Director of Nursing confirmed that staff are required to date all medications upon opening to ensure compliance with manufacturer's guidelines.
Failure to Follow Menu Extension Sheet for Diet Consistency
Penalty
Summary
The facility failed to adhere to the menu extension sheet for providing appropriate portion sizes for residents on mechanical soft and pureed diets. During a lunch meal service, the cook used incorrect scoop sizes, resulting in residents on mechanical soft diets receiving less than the required portion of Lemon Baked Tilapia. Additionally, a resident on a pureed diet with double protein did not receive the correct portion sizes for Lemon Baked Tilapia and zucchini, nor did they receive pureed soup or bread, which are standard offerings for all consistency diets. The dietary manager was unaware of the correct portion sizes and expressed dissatisfaction with the menu program, indicating a lack of familiarity with the facility's dietary procedures. The dietitian later confirmed the correct portion sizes and scoop sizes that should have been used, highlighting the discrepancies in the meal service. The facility's failure to follow the menu extension sheet affected six residents who were reviewed for dining, indicating a systemic issue in the dietary service process.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices during the provision of care to residents, as observed in multiple instances. One resident, who was dependent on staff for activities of daily living, had a urinal with urine left on their overbed tray table during meal times, which was not removed by staff. This practice was observed on multiple occasions, indicating a lack of proper hygiene and infection control measures. In another instance, two therapists failed to wear the required personal protective equipment, such as gloves and gowns, while providing therapy to a resident on Enhanced Barrier Precautions due to an indwelling catheter. This was despite clear signage and facility policy requiring such precautions to prevent the transmission of multi-drug resistant organisms. Additionally, a nurse administered insulin using a syringe that had been dropped and contaminated, and another nurse handled medications with bare hands after they were dropped, both actions contrary to infection control protocols. Further deficiencies were noted when a nurse failed to change gloves and perform hand hygiene between handling a urinary catheter bag and a PICC line, risking cross-contamination. Another nurse used bare fingers to handle medication and failed to change gloves and perform hand hygiene between resident contact and medication handling. These actions demonstrate a pattern of non-compliance with established infection control guidelines, potentially compromising resident safety.
Failure to Maintain Functioning Elopement Alarm System
Penalty
Summary
The facility failed to ensure the proper functioning of the electronic monitoring alarm control panel, which is crucial for the safety of residents at high risk for elopement. This deficiency was identified during an observation on April 1, 2025, when a resident with an electronic monitoring device on his ankle approached the main exit door, and the alarm did not activate. The alarm control panel was found to be without power, and the Maintenance Director confirmed that the transformer was not working and needed replacement. Four residents, all identified as high risk for elopement, were affected by this deficiency. These residents had various diagnoses, including dementia and cognitive impairments, and were equipped with electronic monitoring devices as per physician orders. The facility's guidelines require that these devices and the exit door alarms be checked daily for functionality, but the failure of the alarm system indicates a lapse in this protocol. The deficiency was observed in the context of the facility's elopement and search guidelines, which mandate the use of elopement prevention devices for residents assessed as high risk. Despite these guidelines, the malfunctioning alarm system compromised the safety measures intended to prevent elopement, as evidenced by the non-functioning alarm when tested with a resident at risk.
Failure to Update Smoking Assessment and Care Plan
Penalty
Summary
The facility failed to conduct a smoking assessment and revise the care plan for a resident who resumed smoking. The resident, who has a history of type 2 diabetes mellitus, cerebral infarction, and liver cancer, was admitted to hospice care in February 2025. Despite being cognitively intact, the resident's electronic medical records did not reflect a current smoking assessment or care plan, even though the resident had signed a smoking contract in April 2024. The facility's policy requires smoking assessments to be performed upon admission, quarterly, or with any changes affecting the resident's safety, but this was not adhered to when the resident resumed smoking. Interviews with facility staff revealed a lack of awareness regarding the resident's current smoking status. The Social Service Assistant and Director were unaware that the resident had resumed smoking, despite the resident's own admission and observations of the resident smoking outside the facility. The resident's smoking activities were facilitated by a hospice volunteer and nursing staff, who provided access to cigarettes and a lighter. The facility's policy mandates that all residents desiring to smoke must have a smoking assessment and care plan developed by the interdisciplinary team, which was not updated in this case, leading to the deficiency.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident who requires total assistance with personal care. The resident, who is non-verbal and has severe cognitive impairment due to Alzheimer's disease, was observed with overgrown toenails and very dry skin on the feet. The toenails were noted to be growing sideways, with the left big toenail slightly misaligned and separated from the nail matrix, creating a gap with an unknown black substance. The right big toenail was also sticking sideways and measured 1.8 cm in length. The nurse (LPN) acknowledged that the facility's CNAs or hospice CNA staff should notify nurses when a podiatry consult is needed for toenail clipping. However, the nurse was unable to confirm when the resident was last seen by a podiatrist. The Director of Nursing stated that toenails should be assessed by staff and referred for podiatry consult if needed, with consent obtained from the resident or family member. The facility's policy on nail care emphasizes daily cleaning and regular trimming to prevent infections and skin problems, which was not adhered to in this case.
Failure to Follow Oxygen Administration Orders and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to the physician's order for oxygen administration for a resident with multiple diagnoses, including acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. The resident was observed receiving oxygen at one liter per minute via nasal cannula, contrary to the physician's order for two liters per minute. This discrepancy was acknowledged by the Director of Nursing, who confirmed that oxygen is considered a medication and must be administered as per the physician's order. Additionally, the facility did not follow its policy regarding the maintenance of oxygen equipment. The oxygen tubing, dated March 23, 2025, was not changed weekly as required, and the humidifier bottle was nearly empty with no bubbles, indicating a lack of moisture being provided to the resident. The Director of Nursing acknowledged these oversights, which are contrary to the facility's policy that mandates regular checks and maintenance of the oxygen equipment to ensure proper infection control and adequate moisture delivery to residents.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to adhere to physician's orders during medication administration, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was identified during the administration of medications to a resident (R15) by a nurse (V8). The nurse administered 10 ml of Lactulose Solution and 6 units of Novolog to the resident, despite the Medication Administration Record (MAR) indicating that the resident was supposed to receive 30 ml of Lactulose and 4 units of Novolog based on a blood sugar reading of 213 mg/dl. The Director of Nursing (V2) confirmed that medications must be administered according to physician orders, following the facility's policy and the 5 rights of medication administration, which include the right dose.
Failure to Provide Nutritive Meal Substitutes
Penalty
Summary
The facility failed to provide lunch meal options of similar nutritive value to the main entree for two residents. During a lunch meal service, two residents received a grilled cheese sandwich with a side of zucchini as a substitute for the main meal of Lemon Baked Tilapia, Wild Rice Blend, and Sliced Zucchini. The meal tickets indicated that the residents had ordered the grilled cheese sandwich as a substitute. The cook prepared the sandwiches using two slices of American cheese and two slices of bread. The dietitian confirmed that the Lemon Baked Tilapia portion provided 21 grams of protein, while the grilled cheese sandwich only provided 6 grams of protein due to the use of two slices of cheese. The dietitian agreed that the facility should have offered an additional item to meet the nutritional needs of the substitute meal. The facility's policy on selective menus, effective June 2023, states that selections should be provided within allowed dietary modifications to create nutritious menus and portion control.
Failure to Provide Adaptive Eating Equipment for Resident
Penalty
Summary
The facility failed to assess and provide appropriate adaptive eating equipment for a resident with limited range of motion in the upper extremities, leading to difficulties in eating independently. The resident, who had multiple diagnoses including dementia and cerebral conditions, was observed on two separate occasions struggling to eat independently due to the inability to use the left arm and hand. During these observations, the resident was seen dropping food on the table, floor, and protective clothing while attempting to eat with a fork using only the right hand. Despite these challenges, no staff assistance was provided during the initial observations, and the resident continued to struggle with self-feeding. The Director of Nursing was informed of the situation and acknowledged the need for an assessment of adaptive equipment. Subsequently, the Restorative Nurse assessed the resident and determined that a scoop plate would aid in preventing food spillage and improve the resident's ability to eat independently. The assessment also noted that the resident could grip regular utensils and did not require special utensils. The Director of Nursing emphasized the expectation for nursing staff to report any resident needing adaptive equipment to ensure prompt assessment and provision of necessary tools to maintain nutritional intake.
Failure to Provide Timely Tracheotomy Care
Penalty
Summary
The facility failed to provide timely tracheotomy care to a resident, leading to severe respiratory distress and hospitalization. The resident, a male with a history of cerebral infarction, hemiplegia, chronic respiratory failure, tracheotomy, and gastrostomy, required frequent suctioning to maintain airway patency and oxygen levels. On the night of the incident, the resident experienced breathing difficulties, with oxygen saturation dropping to 86%. Despite the presence of a suction setup at the bedside, there is no documentation that the agency nurse on duty suctioned the resident during this period of distress. Interviews with staff and emergency medical services (EMS) personnel revealed that the resident was found in severe respiratory distress, with significant mucus and secretions obstructing the tracheotomy. The EMS crew had to perform extensive suctioning, which significantly improved the resident's condition. The resident's roommate reported that the resident had been struggling to breathe for an extended period, up to 90 minutes, before receiving appropriate care. The facility's Director of Nursing acknowledged the lack of documentation regarding suctioning during the critical period. The facility's tracheotomy care policy requires suctioning as needed, yet the agency nurse on duty did not provide the necessary care, resulting in the resident's condition worsening. The report highlights the disorganization within the facility, as noted by EMS personnel, and the frequent use of agency nurses who may not be familiar with the residents' specific needs. The Ombudsman also received complaints about the facility's failure to provide adequate suctioning, leading to the resident's severe respiratory distress and subsequent hospitalization.
Failure to Monitor Resident's Decline in Health
Penalty
Summary
The facility failed to adequately monitor a resident experiencing a decline in health condition, leading to a deficiency in care. The resident, who had multiple complex medical diagnoses including heart failure, end-stage renal disease, and cognitive communication deficit, was admitted to the facility in July 2024. On September 23, 2024, the resident exhibited signs of lethargy and a decreased ability to eat independently, which was a significant change from their normal alert and oriented state. Despite these changes, there was a lack of consistent monitoring and documentation of the resident's condition by the nursing staff. The resident's condition continued to deteriorate over the following days, with reports of increased lethargy, refusal to eat, and confusion. Although the nursing staff was instructed by the primary physician to closely monitor the resident's condition, including vital signs and neurological checks, there was insufficient documentation to show that these instructions were followed. The resident was eventually sent to the hospital on September 25, 2024, after becoming unresponsive and was admitted to the ICU with a diagnosis of seizures and encephalopathy. Interviews with staff and family members revealed that the resident's decline was noted by multiple caregivers, yet there was a failure to consistently communicate and document these observations. The lack of timely and thorough monitoring and documentation contributed to the delay in addressing the resident's worsening condition, ultimately resulting in the resident's hospitalization.
Failure to Provide Adequate Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene for six residents who were dependent on assistance for activities of daily living (ADLs). Observations revealed that residents had long, jagged fingernails, oily hair, and dry, flaking skin. For instance, one resident was observed with long, jagged fingernails and was noted to be dependent on staff for all personal care due to severe cognitive impairment and physical disabilities. Another resident had long, oily hair and severely dry, flaking skin on his feet, and reported receiving only occasional sponge baths and no lotion for months despite being bedridden and dependent on staff for personal care. Interviews with residents and staff further highlighted the deficiencies. One resident mentioned not receiving a scheduled shower due to a lack of available help, while another expressed frustration over not having their nails cut despite repeated requests. Staff interviews confirmed that personal hygiene tasks such as nail trimming and applying lotion were not consistently performed, which could lead to potential health risks like infections and skin tears. The Director of Nursing and Assistant Director of Nursing acknowledged that ADLs should be performed as needed and that the current state of residents' hygiene was unacceptable. The facility's policy on activities of daily living, dated February 2023, emphasized the importance of providing necessary care and services to ensure residents' mobility and ADLs do not diminish. However, the observations and interviews indicated a failure to adhere to this policy, resulting in inadequate personal hygiene care for the affected residents. The residents' medical records and care plans consistently showed a need for substantial assistance with personal hygiene, yet the facility did not meet these needs, leading to the identified deficiencies.
Failure to Update Physician Orders for Resident's DNR Status
Penalty
Summary
The facility failed to update physician orders to reflect a resident's resuscitation choice of DNR (Do Not Resuscitate). This deficiency was identified for a resident with multiple diagnoses including dementia, anxiety, dysphagia, morbid obesity, hypertension, bradycardia, pain, and weakness, who was admitted to hospice care. Despite having a signed POLST (Practitioner Order for Life Sustaining Treatment) requesting comfort-focused treatment and allowing a natural death, the resident's current physician order in the EMR (Electronic Medical Record) incorrectly listed the resident as full code. The resident's care plan goal for hospice was to experience death with dignity and physical comfort, and their advanced directive wishes were to be honored. During interviews, staff members including an LPN, a CNA, and a restorative aide/CNA indicated that the resident's code status should be DNR and that the code status could be found in various locations such as the computer, the crash cart, and the EMR. However, the inconsistency between the POLST and the physician's order was confirmed by the DON and the Administrator, who stated that the physician's order should be consistent with the resident's choice on the POLST. The facility's policy on Advanced Directives, dated November 2016, requires the care plan team to initiate the necessary process to modify the status change in the resident's record and secure appropriate orders to reflect the status change, which was not followed in this case.
Failure to Verify G Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to verify the placement of a gastric tube (G tube) for a resident before administering medications. The resident, a male with chronic respiratory failure, type 2 diabetes, tracheostomy, and gastrostomy, was observed receiving medications via his G tube without the nurse checking for residual or verifying the tube's placement. The nurse admitted to not verifying the placement and acknowledged that this step is necessary to prevent fluids and medications from entering the lungs. The Director of Nursing confirmed that the nurse should have verified the G tube placement before administering any medications or flushes. The facility's policy on Enteral Tube Medication Administration mandates the safe and effective administration of medications via enteral tubes, which was not followed in this instance.
Failure to Provide Adequate Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide adequate respiratory care for four residents who required continuous oxygen therapy and proper storage of respiratory equipment. One resident was observed being wheeled to the therapy room without their oxygen supply connected, resulting in the resident gasping for breath. Additionally, the same resident's nebulization mask was repeatedly found uncovered on the bedside table. Another resident's nebulization mask was also observed uncovered on multiple occasions, and the resident's son reported that the facility staff never cleaned or changed it. The Assistant Director of Nursing confirmed that the nebulization containers should be washed and dried for the next use and that all respiratory masks should be bagged when not in use. However, the Director of Nursing admitted that there was no specific policy for storing nebulization masks to avoid contamination. A third resident's BIPAP mask was found uncovered on the bedside table, and the Director of Nursing acknowledged the high risk of bacterial contamination if respiratory equipment is not properly stored. The fourth resident's nebulizer mouthpiece was also observed uncovered on multiple occasions. These deficiencies were observed despite the residents having significant medical conditions such as chronic obstructive pulmonary disease, dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. The facility's failure to ensure proper respiratory care and equipment storage posed a risk of infection and compromised the residents' respiratory health.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to provide thickened drinks as ordered by the physician for a resident with swallowing difficulties. The resident, who has diagnoses including dementia, anxiety, dysphagia, morbid obesity, hypertension, bradycardia, pain, and weakness, was observed receiving unthickened coffee and juice from a family member. The resident's physician had ordered a puree diet with nectar thick liquids due to the resident's swallowing difficulties, which included loss of liquids/solids from the mouth and coughing or choking during meals. Despite this, the resident was given thin liquids, which was confirmed by the LPN and the DON, who acknowledged the error but could not identify the staff member responsible. The dietician also confirmed that residents requiring thickened liquids should not be served thin liquids due to the risk of aspiration.
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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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