Lemont Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lemont, Illinois.
- Location
- 12450 Walker Road, Lemont, Illinois 60439
- CMS Provider Number
- 145901
- Inspections on file
- 30
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lemont Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with a stage 4 sacral pressure ulcer, dementia, and dysphagia did not receive key elements of ordered pressure ulcer management, including consistent offloading, correct specialty mattress settings, and prescribed nutritional supplements. Over an extended observation period, staff entered the room for care tasks but did not reposition the resident to offload the wound, while the WCC stated that an alternating-pressure mattress replaced the need for manual turning and repositioning. The mattress remained incorrectly set for a significantly higher weight than the resident’s documented weight despite orders to verify settings each shift, and electronic records showed numerous missed doses of an ordered arginine supplement intended to support wound healing, even as the wound physician documented deterioration and stressed the need for offloading and high-protein nutrition.
A resident with dehydration, DM, a stage 4 sacral pressure ulcer, dementia, dysphagia, and documented unintended weight loss had physician orders for a NAS/LCS mechanical soft diet with double portions, Mighty Shakes at breakfast and lunch, Med Pass BID, and HS snacks, and was care planned to need partial to moderate assistance with eating. Observations showed the resident repeatedly received regular portions without the ordered supplements, and a CNA stated feeding assistance was unnecessary despite the care plan. The resident’s family reported ongoing concerns about weight loss, lack of feeding assistance, and missing supplements, and supplied their own protein shake when the facility did not provide it. The resident was subsequently hospitalized with a diagnosis of failure to thrive and severe malnutrition with muscle wasting, confirmed by a hospital RN.
A facility failed to provide a resident's Advance Directives to paramedics and the hospital during a transfer. The resident, who was cognitively intact and wished to remain DNR, was transferred due to shortness of breath. The LPN responsible for the transfer did not include the POLST form, and the facility's policy did not require it. The resident's daughter later requested the form be sent, highlighting the oversight.
A resident with a history of UTIs experienced a delay in urine specimen collection, leading to a confirmed UTI at urgent care. Despite a lab order placed, the urinalysis was not transcribed promptly, and the initial specimen was contaminated. The resident's family took her to urgent care, where the UTI was confirmed, and she returned with an IV line.
A resident with swallowing difficulties and significant weight loss was not provided a physician-ordered pureed diet, receiving a mechanical soft diet instead. The dietary change was delayed due to communication issues between nursing and dietary staff, and the facility lacked a policy for diet order implementation.
A resident with multiple health issues, including stage 4 pressure ulcers and cerebral palsy, was found in a neglected state, with greasy hair, unkempt nails, and food remnants on their body. The resident, dependent on staff for all ADLs, was on contact isolation for MRSA. A CNA from an agency, unfamiliar with the resident's care, acknowledged the hygiene issues. The DON confirmed that CNAs are responsible for daily hygiene care, but the facility failed to meet the resident's needs.
A resident with swallowing difficulties and significant weight loss was not provided with a physician-ordered pureed diet due to a communication breakdown between nursing and dietary staff. The resident was served a mechanical soft diet, which posed a risk of aspiration, despite the diet change being documented in the electronic medical records.
The facility failed to maintain proper food storage and sanitation practices, risking foodborne illness for 128 residents. Observations revealed improper storage of opened food items, lack of labeling and dating, and inadequate sanitation practices. Dented cans, dirty equipment, and incomplete logs further highlighted the facility's non-compliance with its policies.
The facility failed to provide adequate grooming and hygiene care for residents requiring assistance, as observed in five residents with cognitive and physical impairments. These residents were found with long, dirty fingernails and inadequate oral care, despite facility policies emphasizing routine cleaning and trimming. The DON acknowledged that CNAs are responsible for these tasks, but they were not being performed as required.
A facility failed to securely store controlled substances and allowed unauthorized bedside storage of medications. Narcotics were found in unlocked refrigerators, and some residents had medications at their bedside without proper orders or assessments. The facility's policies require secure storage and authorized access, which were not followed, posing potential risks to resident safety.
The facility failed to maintain proper infection control practices, with staff not adhering to Enhanced Barrier Precautions and contact isolation protocols. Instances included care provided without necessary PPE due to unavailability, and inadequate hand hygiene practices. These deficiencies were observed in residents requiring EBP and contact isolation, highlighting systemic issues with PPE availability and protocol adherence.
Two residents experienced breaches in privacy and dignity during care activities. A resident with cognitive impairment was left exposed with an open door during bathing, while another resident's urine collection bag was visible, and he was left uncovered during care. The facility's guidelines on resident privacy were not followed.
The facility failed to provide written notification to residents and their families regarding hospital transfers and did not notify the ombudsman. Three residents were transferred for various medical conditions without proper written documentation or communication of the facility's bed hold policy. The DON acknowledged the lack of compliance with notification requirements.
The facility failed to provide written documentation of the bed hold policy to residents or their representatives during hospital transfers. In three cases, residents were transferred to the hospital without receiving the required documentation, and the facility also did not notify the ombudsman of these transfers. The DON acknowledged the lack of written documentation, despite the facility's policy requiring it.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in documenting functional limitations in range of motion (ROM). A male resident with cerebral infarction and hemiplegia was observed with a contracted right hand, yet his MDS documented no impairment in ROM. Similarly, a female resident was observed with contracted hands, but her MDS also failed to reflect any functional limitation in ROM. The MDS Coordinator and DON acknowledged the inaccuracies.
A resident's nephrostomy dressing was not changed daily as ordered, leading to a deficiency in care. The resident's daughter noticed the dressing was dated five days earlier, and the wound nurse did not change it despite it being loose. The DON confirmed the expectation for daily dressing changes to prevent infection.
The facility failed to implement fall interventions for two residents at risk for falls. One resident's bed was not secured, causing it to move during transfers, and the safety ring was not properly attached. Another resident was observed without proper footwear, increasing the risk of falls. Both residents had a history of falls and their care plans required specific interventions that were not followed.
The facility failed to conduct required gradual dose reductions (GDR) for psychotropic medications for two residents. One resident with multiple mental health diagnoses did not receive a GDR in October 2024, and there was no behavior monitoring documentation due to an EMR system change. Another resident with psychosis, major depression, and anxiety disorder did not have any GDR attempts since the psychiatrist retired, and lacked signed medication consent forms.
Two residents in the facility were administered incorrect medication dosages, resulting in a 7.14% error rate. An LPN gave one resident double the prescribed Potassium Chloride, while another resident received more Vitamin D3 than ordered. The errors were due to discrepancies in medication orders and a failure to adhere to the facility's medication administration policy.
A resident was found with a malfunctioning bed control that had exposed and broken wires, posing a safety risk. The DON acknowledged the issue, emphasizing the potential for shock or malfunction. Facility policy requires immediate reporting of unsafe equipment.
The facility failed to serve meals at scheduled times, affecting all 129 residents. Observations and resident interviews revealed consistent delays in meal services, with lunch and dinner being served hours late. Staffing issues and lack of adherence to the facility's mealtime policy were identified as contributing factors.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 129 residents. Observations included dirty rags, grime, and debris in the dish machine area, improperly stored clean dishes, and a disorganized dry storage area. Additionally, improper dishwashing practices and contamination during pureed meal preparation were noted, indicating a failure to follow the facility's sanitation and infection control policies.
The facility failed to provide adequate grooming and hygiene care for four residents who require assistance with ADLs. Observations revealed long dirty fingernails, overgrown facial hair, uncombed greasy hair, and foul odors. Staff interviews and documentation confirmed that scheduled grooming and hygiene care were not consistently provided.
The facility failed to serve the correct portions of mechanical soft fish as specified in the menu spreadsheet. Residents received 2 + 2/3 oz per serving instead of the required 5 + 1/3 oz, and did not receive gravy with their fish. The cook on duty was unaware of the menu spreadsheet and used the incorrect scoop size due to the unavailability of the correct #6 scoop.
The facility failed to follow standard infection control practices during incontinence care and when entering isolation rooms. CNAs did not perform proper hand hygiene or change gloves between tasks, and housekeeping staff did not wear required PPE when cleaning isolation rooms, despite clear signage. This affected multiple residents on contact isolation for infections such as MRSA and VRE.
The facility failed to document that influenza and pneumococcal vaccines were offered to five residents, despite their medical histories and the facility's policies. This includes residents with conditions such as cerebral infarction, pneumonia, and heart failure, who had no records of being offered or receiving the vaccines since admission.
A resident with multiple diagnoses and a physician's order for hydrocodone-acetaminophen experienced severe pain due to the facility's failure to provide timely medication and notify the physician. The resident reported high pain levels and was unable to eat, but staff did not take prompt action to address the issue.
The facility failed to monitor and document the clinical condition of a resident upon returning from dialysis and did not provide clinical documentation during dialysis treatment. The resident had no physician orders for dialysis or monitoring the dialysis access shunt site, and the facility did not receive or follow up on reports from the dialysis company. Additionally, there was no documentation of post-dialysis assessments in the resident's medical record.
The facility failed to identify the diagnosis and specific behavior for residents prescribed antipsychotic medication. Three residents were observed to have no documented behaviors justifying the use of Quetiapine, and their care plans did not target any specific behaviors or diagnoses for the medication. Staff and the Medical Director confirmed the lack of psychiatric evaluations and documentation.
A facility failed to ensure proper medication administration when an agency nurse attempted to give a resident insulin belonging to another resident. The nurse did not follow the facility's policy, which mandates a triple check of the five rights during medication preparation and administration.
The facility failed to provide substitute meals with the same nutrient content for three residents. The menu listed Lemon Baked Fish with 2 ounces of protein, but the substitute grilled cheese sandwiches were made with insufficient cheese, not meeting the required protein content.
Failure to Implement Comprehensive Pressure Ulcer Management Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement key components of a comprehensive pressure ulcer management plan for a resident admitted with a stage 4 sacral pressure ulcer, dementia, and dysphagia. The resident required total assistance with bed mobility and was to be turned and repositioned in bed as necessary, but during an observation period of over two hours, staff were seen entering the room for perineal care, linen removal, blood sugar checks, and wound care without evidence of repositioning to offload the sacral wound. The resident’s niece reported that the resident had not been positioned to offload the wound during that shift and stated that the Wound Care Coordinator (WCC) had told her manual turning was unnecessary due to the alternating-pressure mattress. The WCC confirmed that belief, stating that residents on alternating-pressure mattresses do not require manual turning every two hours and that the mattress takes the place of manual turning, repositioning, and offloading, despite the facility Kardex indicating the need for turning and repositioning. The facility also failed to ensure proper use and monitoring of the resident’s specialty mattress and nutritional supplement ordered to support wound healing. The alternating-pressure mattress was observed on three consecutive days to be set for a 160 lb person, while the resident’s most recent documented weight was 125.6 lbs, even though the physician order required staff to check and ensure mattress settings matched the resident’s weight each shift. The mattress manufacturer’s manual specified that the system is intended for prevention and treatment of pressure ulcers when used with a comprehensive pressure ulcer management program and did not state that it replaces offloading, manual turning, or repositioning. Additionally, the resident’s physician orders included an arginine powder nutritional supplement three times daily since admission, but electronic medication records showed 75 missed doses documented as not available or awaiting pharmacy delivery. A prior wound assessment by the wound physician documented deterioration of the lower back wound, including new undermining, watery drainage, pale granulation tissue, and less organized wound base, and emphasized the imperative need for continued offloading and supervision of high-protein nutrition.
Failure to Provide Ordered Double Portions and Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered therapeutic nutrition interventions, including double portions and prescribed nutritional supplements, to a resident with multiple high-risk diagnoses. The resident was admitted with dehydration, diabetes mellitus, a stage 4 sacral pressure ulcer, dementia, dysphagia, and was care planned as needing partial to moderate assistance with eating due to an ADL self-care deficit. Physician orders specified a NAS/LCS mechanical soft diet with Mighty Shakes at breakfast and lunch with double portions, Med Pass twice daily, and bedtime snacks, as well as notification of the primary physician for significant weight changes. The facility’s policy on Interventions for Unintended Weight Loss required identification and monitoring of individuals with unintended or insidious weight loss so that appropriate interventions could be implemented. On multiple observations, the resident did not receive the ordered double portions or nutritional supplements, and staff did not provide the level of feeding assistance identified in the care plan. During breakfast and lunch observations, the resident’s meal trays lacked the ordered supplements, and the entrees were served as regular portions instead of double portions. The resident’s niece reported repeated concerns to staff about the resident’s weight loss and stated that staff were not assisting with feeding, not providing double portions, and not supplying ordered nutritional supplements; she also indicated that the protein shake at the bedside was brought in by family and that a milkshake ordered with breakfast was not provided. A CNA stated there was no need to assist the resident with feeding because he was independent, which conflicted with the care plan indicating a need for partial to moderate assistance. The resident was later hospitalized with an admitting diagnosis of failure to thrive and severe malnutrition with muscle wasting, which was confirmed by the hospital RN.
Failure to Provide Advance Directives During Resident Transfer
Penalty
Summary
The facility failed to provide documentation of a resident's Advance Directives (AD) to the paramedics and the hospital during a transfer. The resident, who was cognitively intact and had a documented wish to remain Do Not Resuscitate (DNR), was transferred to the hospital due to shortness of breath. Despite the resident's clear wishes and the presence of a Practitioner Order for Life-Sustaining Treatment (POLST) form, the necessary documentation was not sent with the resident during the transfer. The Licensed Practical Nurse (LPN) responsible for the transfer only provided the paramedics with the resident's face sheet and medication list, omitting the POLST form. The LPN was unaware that the POLST documentation should have been included, and this oversight was not addressed by the facility's policy, which only required the face sheet and medication list to be sent. The resident's daughter, who held Power of Attorney, later requested that the POLST form be sent to the hospital, highlighting the facility's failure to adhere to state law protocols requiring the provision of such documentation during transfers. The Emergency Medical Services (EMS) transport report confirmed that no Advance Directives were provided during the transfer. The facility's Social Service Director and the EMS Director both validated that the necessary documentation was not included. The resident's daughter expressed concern that the omission could have led to the resident's wishes not being honored, although the resident did not experience a code situation during the transfer or at the hospital.
Delayed Urine Specimen Collection Leads to UTI Confirmation at Urgent Care
Penalty
Summary
The facility failed to obtain a urine specimen in a timely manner for a resident, identified as R2, to rule out a urinary tract infection (UTI). R2 was admitted to the facility with a history of UTIs, ESBL resistance, acute kidney failure, and anemia of chronic disease. On January 21, 2025, a nursing progress note indicated that R2's daughter expressed concern about her mother's paranoia, suspecting a UTI. A lab order was placed for a urine sample to be collected the following morning. However, the order for the urinalysis and culture was not transcribed until January 25, 2025, leading to a delay in obtaining the necessary specimen. On January 25, 2025, it was noted that the initial urine collection was contaminated due to a loose lid on the specimen cup. The family opted to take R2 to urgent care, where a UTI was confirmed. The psychiatric nurse practitioner, V7, expressed that the resident should not have waited four days for the urine collection. The Director of Nursing confirmed that R2 was taken to urgent care by her family, where a urinalysis confirmed the UTI. R2 returned from the hospital with an IV line, indicating further treatment was necessary. The facility's policy requires that telephone and verbal orders be promptly recorded, which was not adhered to in this case.
Failure to Implement Physician-Ordered Pureed Diet
Penalty
Summary
The facility failed to provide a pureed diet as ordered by a physician for a resident with a history of swallowing problems, leading to significant weight loss. The resident, who was diagnosed with conditions including dysphagia, severe protein-calorie malnutrition, and cerebral palsy, was dependent on staff for all activities of daily living, including eating. Despite a physician's order for a pureed diet, the resident was served a mechanical soft diet, which was not suitable given their swallowing difficulties. The deficiency was identified when the resident was observed receiving a meal that did not comply with the prescribed pureed diet. The dietary manager acknowledged receiving a form to change the diet from mechanical soft to pureed only on the day of the observation, indicating a delay in implementing the diet change. The Assistant Director of Nursing had downgraded the diet to pureed earlier in the month, but the change was not communicated effectively to the dietary department, resulting in the resident continuing to receive the incorrect diet. The Speech Therapist confirmed that the resident was at risk of aspiration on a mechanical soft diet due to suboptimal positioning and recommended maintaining the pureed diet with thin liquids. The Medical Director stated that the facility should implement diet changes within 24 hours, but this did not occur. The facility lacked a policy for the process of diet order implementation, contributing to the oversight and the resident's subsequent weight loss.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care to a resident who was dependent on staff for all activities of daily living (ADLs). The resident, who had multiple diagnoses including osteomyelitis, stage 4 pressure ulcers, severe protein-calorie malnutrition, and cerebral palsy, was observed in a state of neglect. The resident was found in bed with greasy, uncombed hair, long jagged fingernails with a blackish substance underneath, and remnants of food particles and stains on their chin and pillow. Additionally, a powdery blackish substance was noted on the resident's neck and upper chest. The resident was on contact isolation for MRSA, requiring gown and gloves for room entry. The observations were made by a registered nurse and a certified nursing assistant (CNA) who was from an agency and unfamiliar with the resident's care routine. The CNA acknowledged the resident's unkempt state and indicated that student nurses had fed the resident earlier but did not address the hygiene issues. The Director of Nursing confirmed that CNAs are responsible for providing daily personal hygiene care and acknowledged the difficulty in cutting the resident's nails due to contractures. The facility's policy on ADLs emphasized the importance of providing care in accordance with the resident's needs and preferences, yet the resident's hygiene needs were not met, leading to the deficiency.
Failure to Provide Physician-Ordered Pureed Diet
Penalty
Summary
The facility failed to provide a pureed diet as ordered by a physician for a resident with a history of swallowing problems. The resident, who was diagnosed with conditions such as dysphagia and severe protein-calorie malnutrition, was supposed to receive a pureed diet starting January 9, 2025. However, on January 16, 2025, the resident was served a mechanical soft diet instead. This discrepancy was due to a communication breakdown between the nursing staff and the dietary department. The dietary manager did not receive the diet change form until January 16, 2025, and the resident's diet card still indicated a mechanical soft diet. The resident's weight had decreased significantly, with an 8.9% loss since December 17, 2024, which was not planned or desired. The speech therapist confirmed that the resident was at risk for aspiration on a mechanical soft diet and recommended maintaining the pureed diet with thin liquids. Despite the nursing staff's attempt to downgrade the diet in the electronic medical records and notify the dietary manager, the change was not implemented in time, resulting in the resident receiving an inappropriate diet that could potentially compromise their health.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and handling practices, which could lead to foodborne illness among the 128 residents receiving dietary services. Observations revealed that the dry storage area contained opened jars of mayonnaise and barbeque sauce that were not refrigerated as required, and dented cans of peaches and sauerkraut were improperly stored without signage. Additionally, the plate warmer was found to be dirty, and the facility's policy on the storage and handling of cleaned equipment was not adhered to. In the walk-in cooler, several food items were found without proper labeling or use-by dates, including hard-boiled eggs, various juices, sliced pickles, yogurt, and meat products. These items were stored improperly, with meat placed above vegetables, risking cross-contamination. Employee food items were also stored alongside facility food, which is against policy. The facility's failure to label and date food items could result in serving expired or allergen-containing foods to residents. The facility's sanitation practices were also deficient. The sanitizer level in the three-compartment sink was found to be below the required concentration, and the logs for food temperature, freezer, walk-in cooler, and sanitizer solution concentration were incomplete. Cleaning products were improperly stored in food preparation areas, and the facility's policy on sanitation and infection control was not followed. These deficiencies in food storage, labeling, and sanitation practices could potentially compromise the safety and well-being of the residents.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate grooming and hygiene care for residents who require staff assistance, as observed in five out of seven residents reviewed for activities of daily living. These residents, who have varying degrees of cognitive and physical impairments, were found with long, dirty fingernails and inadequate oral care. For instance, one resident with severe cognitive impairment was observed with contracted hands and dirty nails, expressing a desire for assistance in trimming them. Another resident with cerebral infarction and hemiplegia was found with long, dirty nails and stated that no one was helping him with nail care. The facility's Director of Nursing acknowledged that Certified Nursing Assistants are responsible for providing nail trimming and grooming at least on shower days and as needed, but this was not being done. The facility's policies on activities of daily living and nail care emphasize the importance of routine cleaning and regular trimming to prevent skin problems and ensure infection control. Despite these guidelines, multiple residents were observed with long, jagged nails and inadequate personal hygiene, indicating a failure to adhere to the facility's care standards.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to securely store resident medications, specifically controlled substances, as required by regulations. During an inspection, it was observed that the medication storage rooms on two units had medication refrigerators containing narcotics that were not double-locked. In one instance, the key to the refrigerator was left hanging on a hook inside the medication storage room, accessible to anyone entering the room. This oversight involved several residents' medications, including Lorazepam and Dronabinol, which were not stored according to the facility's policy and federal regulations. Additionally, the facility did not ensure that medications were stored safely at residents' bedsides. One resident was found with medications, including Glutose 15 and Fluticasone Propionate nasal spray, on their bedside table without proper orders or assessments for self-administration. Another resident had Miconazole nitrate powder and Sodium Chloride nasal spray at their bedside, also without corresponding physician orders. The Director of Nursing confirmed that residents are not permitted to store medications at their bedside without a physician's order and proper assessment. The facility's policies require that all medications, especially controlled substances, be stored securely and accessed only by authorized personnel. The failure to adhere to these policies and regulations resulted in unsecured storage of narcotics and unauthorized bedside storage of medications, posing potential risks to resident safety and medication management compliance.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) and contact isolation protocols. For instance, a resident with wounds requiring EBP did not have Personal Protective Equipment (PPE) readily available outside their room, leading to staff providing care without wearing necessary isolation gowns. Despite signage indicating the need for PPE, staff members, including a hospice CNA and a facility CNA, did not wear gowns while providing care, citing the unavailability of gowns and lack of access to PPE stored in a locked medication room. Another resident, who required EBP due to a Gastrostomy Tube (GT) feeding, was also cared for without the appropriate use of PPE. A CNA provided incontinent care without wearing a gown, despite the presence of EBP signage. The facility's Director of Nursing and Infection Preventionist confirmed that staff should have worn gowns during high-contact care activities. Additionally, a resident on contact isolation for ESBL had visitors in the room without wearing gowns, contrary to the facility's guidelines for contact isolation. Further deficiencies were observed in the facility's infection control practices, including a CNA providing care without performing hand hygiene between glove changes and feeding two residents without cleaning hands between interactions. These actions were contrary to the facility's hand hygiene guidelines, which emphasize the importance of hand hygiene in preventing the transmission of infectious agents. The report highlights a systemic issue with the availability and use of PPE, as well as adherence to infection control protocols by both staff and visitors.
Privacy and Dignity Breach for Two Residents
Penalty
Summary
The facility failed to protect the privacy and dignity of two residents, R61 and R32, during care activities. R61, who is cognitively intact and has multiple diagnoses including impaired gait and requires substantial assistance with activities of daily living, was left exposed on multiple occasions. His urine collection bag was visible from the hallway, and he was left naked and exposed from the waist to the ankles when a CNA left the room to get assistance, leaving the door open. Although the CNA returned shortly to close the door, R61 remained uncovered until assistance arrived 15 minutes later. R61 expressed a preference for his urine collection bag to be concealed and for his body to be covered during care. R32, who has severe cognitive impairment and is completely dependent on staff for assistance, was also subjected to a lack of privacy. During bathing assistance provided by a hospice CNA, the room door was left open, and no curtain was drawn to shield R32 from view. Although R32 did not express concern due to her cognitive impairment, the facility's Director of Nursing acknowledged that curtains should be closed during care to protect residents' privacy. The facility's Resident Rights Guideline emphasizes the right of residents to be treated with respect and dignity, which was not upheld in these instances.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their families or representatives regarding the reasons for hospital transfers, as well as failing to notify the ombudsman of these transfers. This deficiency was identified in three residents who were transferred to the hospital for various medical conditions. One resident was transferred due to altered mental status and leukocytosis, with the POA notified verbally but not in writing. Another resident was transferred for severe abdominal pain, ascites, and pneumonia, with the spouse notified verbally but lacking written documentation. The third resident was transferred following an unwitnessed fall, with no written notification provided to the resident or family. Additionally, the facility's Director of Nursing (DON) acknowledged the lack of written documentation and ombudsman notification, citing unawareness of the requirement to notify the ombudsman. The facility's bed hold policy was also not properly communicated in writing to the residents or their representatives, as required. The DON admitted that the facility does not have a formal bed hold policy, instead relying on an assessment presented to residents upon leaving the facility. This lack of compliance with notification and documentation requirements constitutes a deficiency in the facility's handling of resident transfers.
Failure to Provide Bed Hold Policy Documentation
Penalty
Summary
The facility failed to provide written documentation of the bed hold policy to residents and/or their representatives when residents were transferred to the hospital. This deficiency was identified in three cases. In the first case, a resident with altered mental status and leukocytosis was transferred to the emergency department, but the facility did not provide the bed hold policy documentation to the resident or their power of attorney (POA). In the second case, a resident experiencing severe abdominal and chest pain was sent to the hospital, and although the resident's wife was notified of the transfer, there was no documentation that the bed hold policy was provided. The Director of Nursing (DON) acknowledged that while families are notified of hospital transfers, there is no written documentation of the bed hold policy being provided. In the third case, a resident was transferred to the hospital following an unwitnessed fall, and again, the facility did not document the provision of the bed hold policy form. The facility's existing bed hold policy states that written information and notice should be given to residents or their legal representatives at the time of admission, in advance of any transfer, and at the time of transfer. However, the facility was unable to provide evidence that this policy was followed in the cases reviewed. Additionally, the facility failed to notify the ombudsman of the residents' transfers to the hospital.
Inaccurate MDS Assessments for ROM Limitations
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in documenting functional limitations in range of motion (ROM). A male resident with cerebral infarction and hemiplegia affecting the right dominant side was observed with a contracted right hand, yet his MDS documented no impairment in ROM. Similarly, a female resident was observed with contracted hands, but her MDS also failed to reflect any functional limitation in ROM. The MDS Coordinator acknowledged that the hand contracture should have been coded in the functional limitation section, and the Director of Nursing confirmed that the MDS assessments did not accurately reflect the residents' statuses, which could lead to inadequate care.
Failure to Change Nephrostomy Dressing as Ordered
Penalty
Summary
The facility failed to implement a physician's order for a resident, identified as R239, who was admitted with several diagnoses including mechanical complications of a nephrostomy catheter and urinary tract infection. The deficiency was observed when the resident's daughter, V9, expressed concerns about the staff not changing the dressing on R239's nephrostomy site daily as ordered. Upon inspection, the dressing was found to be dated five days earlier, indicating it had not been changed daily. This was further confirmed when the wound nurse, V6, did not change the nephrostomy dressing even after noticing it was not fully intact. The physician's orders from November 18, 2024, specified that the nephrostomy site should be cleansed and a new dressing applied daily and as needed if the dressing was loose or soiled. The Director of Nursing, V2, confirmed that the expectation was for the dressing to be changed daily to monitor for infection and prevent complications. However, the facility staff failed to adhere to these orders, resulting in a deficiency in the quality of care provided to the resident.
Failure to Implement Fall Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents at risk for falls. Resident R3 expressed concern about her bed moving when she attempted to transfer from her wheelchair, as the wheels on her bed were unlocked, causing it to move easily. Additionally, the Halo safety ring attached to her bed was not secured and spun around when touched. R3 has a history of falling and her care plan indicated the need for a safe environment, which was not provided as observed by the surveyors. Resident R94 was observed in her wheelchair without proper footwear, wearing socks that were not non-skid or non-slip. R94 reported a history of falls, including incidents where she slipped out of her wheelchair. Her care plan required her to wear appropriate footwear and follow the facility's fall protocol, which was not adhered to. The facility's Falls Guidelines emphasized the need to identify and evaluate residents at risk for falls and to provide an environment free from hazards, which was not achieved in these cases.
Failure to Conduct Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to conduct gradual dose reductions (GDR) for residents taking psychotropic medications, as required by regulatory guidelines. For one resident, identified as R109, the facility's records showed a history of traumatic brain injury, dementia, attention deficit hyperactivity disorder, bipolar disorder, and major depressive disorder. The resident was prescribed Citalopram, Quetiapine, and Trazadone. Although a GDR was performed in April 2024, there was no documentation of a subsequent GDR in October 2024, as required. Additionally, there was no behavior monitoring documentation for this resident, which the Director of Nursing attributed to a change in the electronic medical record (EMR) system. Another resident, identified as R82, was admitted with diagnoses of psychosis, major depression, and anxiety disorder. This resident was receiving Lorazepam, Olanzapine, Trazadone, and Clonazepam. The facility did not attempt any GDR for this resident, and there was no signed psychotropic medication consent on file. The Director of Nursing acknowledged that no GDR had been attempted since the facility's psychiatrist retired in March. The facility's guidelines require GDR to be attempted quarterly, but this was not adhered to for R82.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 7.14%, which exceeds the acceptable threshold of 5%. This deficiency was observed in two residents during a medication pass. The first resident, with diagnoses including dementia, atrial fibrillation, and heart failure, was administered two Potassium Chloride ER 10 meQs tablets instead of the prescribed one tablet twice a day. The LPN responsible for administering the medication noted a discrepancy between the physician's order and her own note, which led to the incorrect dosage being given. The Director of Nursing confirmed that such discrepancies should be clarified with the physician before medication administration, as excessive potassium can be harmful to the heart. The second resident, diagnosed with chronic kidney disease and dementia, received a Vitamin D3 dosage of 125 mcg instead of the prescribed 50 mcg. The LPN administered the incorrect dosage and later confirmed the error upon reviewing the resident's chart. The Director of Nursing was uncertain about the potential harm of the increased Vitamin D3 dosage, although the Springhouse Nurse's Drug Guide indicates possible adverse reactions. The resident's care plan highlighted renal insufficiency related to stage 3 kidney failure, which could be exacerbated by incorrect medication dosages. The facility's policy on medication administration emphasizes the importance of reviewing the '5 Rights' to ensure safe and effective medication administration, which was not adhered to in these instances.
Unsafe Bed Control Poses Risk to Resident
Penalty
Summary
The facility failed to maintain a safe and homelike environment for a resident, identified as R114, due to a malfunctioning bed control. During an observation, the bed control was found wrapped around a safety ring on the resident's bed, with exposed wires and a broken white wire. The Director of Nursing (DON) confirmed the safety issue, noting that the exposed and broken wires could lead to the resident being shocked or the bed control malfunctioning. The facility's policy mandates that unsafe equipment should not be used and must be reported to a supervisor promptly.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve meals at the scheduled times, affecting all 129 residents who receive food prepared in the facility kitchen. During an entrance conference, it was noted that lunch service began after 1:45 PM on April 1, 2024. Residents active in the Resident Council confirmed that meals have been served as late as two hours after the scheduled time, with dinner sometimes being served as late as 8:00 PM. The facility's mealtime schedule indicated that breakfast and lunch should be served between 8:00-8:30 AM and 12:00-12:30 PM, respectively. However, observations showed that meal services were consistently delayed, with lunch service starting at 12:55 PM and the last cart being taken to the floor at 2:15 PM on April 1, 2024. Similar delays were observed on April 2, 2024, with residents expressing dissatisfaction and concern over the late meal times, especially those with specific dietary needs like diabetes who require timely meals for health reasons. Staff interviews revealed that the delays were due to staffing issues, including a cook and a dietary aide calling off, which left the kitchen understaffed. The cook on duty mentioned that he was not used to being the lead cook, which contributed to the delays. The facility administrator acknowledged being aware of the late meal times due to complaints from staff. The facility's policy on mealtimes and frequency states that meals should be served at regular times comparable to standard mealtimes in the community or according to the residents' needs, preferences, and plan of care. However, the facility failed to adhere to this policy, resulting in late meal services and dissatisfaction among residents.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to serve foods in a sanitary manner, affecting all 129 residents who receive food prepared in the facility kitchen. During an initial tour of the kitchen, multiple sanitation issues were observed, including a dirty rag in the hand washing sink, extensive grime and unknown debris in the dish machine area, and improperly stored clean dishes. Additionally, the walk-in cooler had extensive debris on the floor, and the food prep area had multiple dirty rags and soiled sanitizer buckets. The milk refrigerator had congealed spills and a putrid smell, and the dry storage area was disorganized with no first-in, first-out system in place. The spoodle and scoop storage units contained blackish grime and other dirt-like particles, which were not cleaned before use during tray line service. On a subsequent day, a dietary aide was observed improperly washing dishes in the 3-compartment sink, using the second sink for both rinsing and sanitizing due to the third sink being non-functional. This practice did not adhere to the facility's policy for proper dishwashing and sanitation. Additionally, during the preparation of a pureed meal, a cook was observed not following the recipe, touching multiple surfaces with gloved hands, and contaminating the pureed mixture by dipping her gloved fingers into it. The cook also failed to reheat the pureed food to the required temperature of 165 degrees Fahrenheit before service. The facility's policies on sanitation and infection control, as well as dishwashing and sanitation, were not followed. These policies are designed to ensure that food is prepared, handled, and stored in a sanitary manner to prevent contamination and food-borne diseases. The observed deficiencies indicate a failure to adhere to these policies, resulting in unsanitary conditions in the kitchen and improper food handling practices that could potentially affect the health and safety of the residents.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate grooming and hygiene care for residents who require assistance with Activities of Daily Living (ADL). This deficiency was observed in four residents. One resident, who is dependent on staff for ADL care, was found with long dirty fingernails, overgrown facial hair, uncombed greasy hair, and a foul-smelling odor on two separate occasions. Another resident, who requires substantial assistance for grooming and hygiene, reported not receiving a bed bath for two consecutive weeks and was observed with long dirty fingernails. A third resident, who needs supervision or touching assistance for grooming, stated that he had not received a shower for two weeks due to staff shortages. The fourth resident, who requires substantial assistance, was observed with long dirty fingernails and overgrown nasal hair on multiple occasions. Staff interviews revealed that residents are scheduled to receive bed baths or showers twice a week, but documentation for the month of April was missing. The most recent Bath and Skin Report Sheet for March showed that the last time the residents were showered or received a bed bath was mid-March. The Director of Nursing confirmed that showers are scheduled twice a week and that nail care should be provided immediately when needed. However, the facility failed to adhere to these schedules, resulting in the observed deficiencies.
Incorrect Portion Sizes Served for Mechanical Soft Diet
Penalty
Summary
The facility failed to serve the correct portions of mechanical soft fish as specified in the menu spreadsheet. During tray line service, residents on mechanical soft diets received two scoops of ground fish served with a red-handled spoodle, which amounted to 2 + 2/3 oz per serving instead of the required 5 + 1/3 oz. Additionally, the residents did not receive gravy with their fish as indicated in the menu. The cook on duty, who was not the main cook, was unaware of the menu spreadsheet and used the incorrect scoop size due to the unavailability of the correct #6 scoop. The Vice President of Culinary confirmed that the facility should follow the menu spreadsheet to ensure residents receive the required amount of protein.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to follow standard infection control practices during the provision of incontinence care and when entering isolation rooms. Certified Nursing Assistants (CNAs) were observed not performing proper hand hygiene and not changing gloves between dirty and clean tasks. For instance, one CNA washed her soiled gloves instead of changing them, and another CNA did not perform hand hygiene after changing soiled gloves. Additionally, staff did not don full Personal Protective Equipment (PPE) when entering isolation rooms, despite clear signage indicating the need for gowns and gloves. This was observed with multiple residents who were on contact isolation for infections such as MRSA and VRE. Housekeeping staff also failed to adhere to infection control protocols. A housekeeper was seen entering and cleaning isolation rooms wearing only gloves and not the required disposable gown. This occurred despite the presence of signage indicating the need for full PPE. The Director of Nursing confirmed that the housekeeper should have worn a gown and gloves when cleaning these rooms, as organisms could be present anywhere in the room. The housekeeper admitted to not being informed about the need for additional PPE.
Failure to Document Influenza and Pneumococcal Vaccine Offers
Penalty
Summary
The facility failed to provide documentation that influenza and pneumococcal vaccines had been offered to five residents. For instance, an 83-year-old resident with multiple diagnoses, including cerebral infarction and atrial fibrillation, had no documentation of being offered or receiving the vaccines since admission. Similarly, a 95-year-old resident with pneumonia and chronic obstructive pulmonary disease had no record of being offered the pneumococcal vaccine despite CDC recommendations. Another resident, aged 91, with conditions such as metabolic encephalopathy and heart failure, also lacked documentation of being offered or receiving the vaccines since admission. Additionally, an 85-year-old resident with Parkinson's disease and heart failure had no documentation of being offered the PCV20 vaccine, despite having received the PPSV23 vaccine previously. An 89-year-old resident with acute diastolic congestive heart failure and epilepsy had no record of receiving the influenza vaccine for the 2023-2024 flu season or being offered the pneumococcal vaccine. The facility's policies on influenza and pneumococcal vaccines, dated December 2006, were not followed, as there was no documentation of vaccine offers or refusals in the residents' medical records.
Failure to Provide Timely Pain Management and Notify Physician
Penalty
Summary
The facility failed to notify the physician of a resident's pain and provide medication as ordered by the physician. Resident R65, who was readmitted from the hospital with multiple diagnoses including orthopedic aftercare and chronic ulcer, was cognitively intact and had a physician's order for hydrocodone-acetaminophen (Norco) to be administered every 4 hours as needed. Despite this, R65 reported severe pain and requested pain medication multiple times without receiving it. The resident's pain score was consistently high, reaching 9.5 on a scale of 1-10, and the resident was unable to eat due to the pain. The medication administration record showed that Norco was not administered from March 26, 2024, to April 2, 2024, due to the medication being unavailable in the cart and a lack of a refill order from the practitioner. The staff, including the Registered Nurse and Licensed Practical Nurse, were aware of the resident's pain but did not take timely action to obtain the necessary medication or notify the physician promptly. The Director of Nursing only became aware of the resident's severe pain on April 2, 2024, and subsequently obtained a new prescription from the Nurse Practitioner. The facility's policy on pain management, which includes regular reassessment of pain and notifying the physician of significant changes, was not followed. The failure to provide timely pain management and notify the physician resulted in the resident experiencing prolonged and severe pain, impacting their ability to perform daily activities and eat. The Nurse Practitioner confirmed that they were not informed of the resident's high pain levels and would have prescribed additional medication if they had been aware.
Failure to Monitor and Document Dialysis Care
Penalty
Summary
The facility failed to monitor the clinical condition of a resident upon returning from dialysis and did not provide clinical documentation of the resident's condition during dialysis treatment. The resident, a male with acute and chronic congestive heart failure, end-stage renal disease, morbid obesity, and type 2 diabetes mellitus, had no physician orders for dialysis or for monitoring the dialysis access shunt site upon return from dialysis. The Director of Nurses (DON) admitted that the dialysis orders were not reactivated and that the facility did not receive any reports, weights, labs, or communication from the dialysis company post-dialysis sessions. Additionally, the DON did not follow up with the dialysis company when the dialysis log profile forms were not returned after dialysis sessions. The Dialysis RN confirmed that the dialysis company did not receive any forms from the facility to document pre/post dialysis conditions and only received the resident's face sheet and medication list. There was no documentation in the resident's medical record of any assessment after dialysis from March 12, 2024, until April 3, 2024. The facility's dialysis care plan indicated the need to monitor and report signs of localized infection, monitor circulation, motion, and sensation of the extremity with the access device every shift, and palpate the shunt for thrill every shift. However, the facility did not provide a policy for dialysis care and treatment when requested, and the Administrator confirmed that no such policy existed.
Failure to Identify Diagnosis and Specific Behavior for Antipsychotic Medication
Penalty
Summary
The facility failed to identify the diagnosis and specific behavior for residents who are prescribed antipsychotic medication. This deficiency was observed in three residents. One resident, who has multiple medical diagnoses including Parkinson's disease and unspecified dementia, was prescribed Quetiapine but displayed no behaviors warranting its use. Staff and the Director of Nursing confirmed that the resident had no psychiatric evaluation and no documented targeted behavior for the antipsychotic medication. The resident's care plan included monitoring behavior and response to medication, but no specific behaviors were documented to justify the use of Quetiapine. Another resident, diagnosed with unspecified dementia and other conditions, was also prescribed Quetiapine. Observations showed the resident sleeping most of the time, and staff confirmed that the resident currently had no behaviors justifying the medication. The psychiatric evaluation did not document any behavior related to the use of Quetiapine. The resident's care plan mentioned the risk of adverse side effects from psychotropic medications but did not document any targeted behavior for the antipsychotic medication. A third resident, admitted with unspecified dementia and other diagnoses, was prescribed Quetiapine despite having no psychiatric diagnosis or behaviors documented in the facility's records. The Medical Director was unaware of the reason for the prescription. The resident's care plan did not target any behavior or diagnosis for the antipsychotic medication. The facility's policy on psychotropic medications requires documentation of specific conditions or behaviors to justify the use of antipsychotic drugs, which was not followed in these cases.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident was not given insulin belonging to another resident and did not follow the facility's policy regarding medication administration. On April 2, 2024, an agency nurse (V7) was observed preparing to administer insulin to a resident (R115) whose blood sugar was high. V7 could not find the insulin in her cart and retrieved a vial from another cart that had a different resident's (R380) name on it. Despite the surveyor's intervention, V7 initially intended to administer the insulin drawn from the vial labeled for R380, who had been discharged. The insulin was also past its expiration date as per the facility's policy, which states that insulins expire 28 days after being opened. The Director of Nurses (V2) and the facility's pharmacist (V37) confirmed that insulins should not be shared between residents due to safety and infection control concerns. The facility's Medication Administration policy mandates a triple check of the five rights (right resident, right drug, right dose, right route, and right time) during medication preparation and administration. V7 failed to adhere to these protocols, leading to the potential administration of expired and incorrectly labeled insulin to R115.
Failure to Provide Nutrient-Equivalent Meal Substitutes
Penalty
Summary
The facility failed to provide substitute meals with the same nutrient content for three residents. The facility's Fall/Winter menu for Monday listed Lemon Baked Fish as the main entree, which provided a minimum of 2 ounces of protein per serving. During lunch meal preparation, a cook was observed making grilled cheese sandwiches with only 2 slices of cheese, which did not meet the required protein content. The residents had ordered grilled cheese as a substitute for the lemon baked fish. The facility's production recipe for grilled cheese sandwiches specified that 3 slices of cheese were needed to meet the 2-ounce protein requirement. The Vice President of Culinary confirmed that the meal replacement should have the same equivalent of protein servings.
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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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