Loft Rehab Of Peoria, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Peoria, Illinois.
- Location
- 1500 West Northmoor Road, Peoria, Illinois 61614
- CMS Provider Number
- 145647
- Inspections on file
- 48
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Loft Rehab Of Peoria, The during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple chronic conditions reported to the ADON that two CNAs had used foul language and called her a derogatory term. The DON directed that corporate leadership be notified, and corporate staff interviewed the resident and decided it did not qualify as an abuse allegation, though they reassigned the CNAs to another hallway. The CNAs were not suspended, no other staff or residents were interviewed, and no official investigation or documentation was completed, resulting in a failure to conduct a thorough abuse investigation and to fully remove the alleged perpetrators from resident care as required by facility policy.
A resident reported to the ADON that two CNAs used foul language and called her a derogatory name. The ADON relayed the allegation to the DON and then to corporate leadership, who interviewed the resident and concluded it did not qualify as abuse. The facility’s own policy required reporting all alleged violations, including abuse, to the state agency within specified timeframes, but no report of this verbal abuse allegation was submitted, despite the resident later reiterating that staff had called her the derogatory name.
A resident with a history of hypersexual behavior and cognitive impairment was admitted without adequate screening, leading to an incident where he exposed himself and placed his genitals on the lips of another nonverbal, cognitively impaired resident. Staff intervened upon witnessing the event, and subsequent review confirmed that gaps in the admission process contributed to the failure to prevent this abuse.
A resident with a right-hand contracture and impaired mobility did not receive physician-ordered hand protector use or documented range of motion (ROM) services. Staff were unaware of the resident's need for the hand protector, and no assessments or restorative programs were in place, despite facility policy requiring such interventions for contracture prevention.
A resident with multiple chronic conditions and severe cognitive impairment experienced a significant decline in gait, balance, and mental status over two days. Despite clear documentation of these changes, the RN did not promptly notify the physician, instead relaying the information in a shift report. The physician was only informed after the resident was hospitalized and diagnosed with a UTI and altered mental status. Both the LPN and administrator confirmed that timely physician notification was required.
A resident with a known sulfa drug allergy was repeatedly administered Sulfamethoxazole-Trimethoprim (Bactrim), despite clear documentation of the allergy in the care plan and MAR. The pharmacy flagged the allergy and notified nursing staff, but the medication was still given, resulting in the resident developing a rash, sore throat, and difficulty swallowing. Interviews revealed that staff did not appropriately respond to allergy warnings, and the medication was only discontinued after adverse reactions occurred.
A resident reported being hit by a CNA to an Activities Aide, who then informed the Administrator. Despite initiating an investigation, the Administrator did not report the alleged abuse to the State Agency, violating the facility's policy requiring immediate reporting of such incidents.
A resident with multiple medical conditions did not receive prescribed Oxycodone due to a narcotic diversion incident. The facility's investigation revealed that a full card of Oxycodone was missing, and video surveillance showed suspicious behavior by an LPN. Narcotic medications were not consistently counted, and the facility was unable to identify who ordered the medication. The LPN was terminated, and the incident was reported to the police.
The facility failed to provide grievance forms and post grievance procedures in prominent locations, affecting all 89 residents. During a resident council meeting, several residents stated they did not know how to file a grievance. A tour with the Administrator confirmed the absence of posted grievance procedures and readily available forms, indicating non-compliance with the facility's grievance policy.
The facility did not have a Registered Nurse (RN) on duty for at least eight hours on four days, affecting the care of 89 residents. The Administrator and Director of Nursing confirmed the deficiency, acknowledging the requirement for daily RN coverage.
The facility failed to provide adequate personal hygiene care for several residents, including not shaving or showering them as needed. One resident reported not receiving regular showers or shaves due to staff time constraints. Another resident had not been shaved since admission, and documentation for care was lacking. Additional issues included a resident with long chin whiskers and another with untrimmed fingernails, both requiring assistance with personal hygiene.
A resident's call device was found on the floor and out of reach while the resident was in a wheelchair beside his bed. The resident attempted to retrieve the device with his cane but was unsuccessful. A CNA confirmed the device was out of reach and should have been accessible, violating the facility's policy on call light accessibility.
The facility failed to provide written notification of hospital transfers to a resident's representative and did not notify the Ombudsman of discharges/transfers for three residents. One resident's discharge to a new facility was not documented, and another resident's hospital transfer was not recorded in the Admission/Discharge Log. The Administrator in Training admitted the Discharge Report was completed incorrectly, omitting hospital transfers.
The facility failed to provide a copy of the bed hold policy to a resident or their representative when the resident was transferred to a hospital. During a review, it was found that the clinical record for a hospitalized resident did not contain documentation of written notice of the facility's bed hold policy. The administrator was unable to produce any documentation that the policy was provided.
A resident with severe cognitive impairment and a history of aspiration pneumonia was left unsupervised during meals, despite being on a mechanically altered diet requiring supervision. The CNA acknowledged the dietary change but did not provide the necessary supervision, leading to a deficiency in care. The DON confirmed the resident's risk for choking, underscoring the need for adherence to the care plan.
A facility failed to adhere to its Catheter Care policy by not covering a resident's urinary catheter bag and allowing the tubing to touch the floor. This was observed by a CNA and confirmed by the DON, both acknowledging the need for the catheter bag to be covered and elevated.
The facility failed to place oxygen warning signs outside the rooms of two residents receiving oxygen therapy and lacked a physician order for one resident's oxygen use. Additionally, another resident's nebulizer equipment was not changed weekly or stored properly, as required by facility policy.
The facility did not maintain proper documentation of communication with the dialysis center for a resident receiving dialysis. Despite the policy requiring daily communication, the resident's records lacked dialysis communication forms for an extended period, with only two forms available for early and mid-August. The administrator confirmed the deficiency in documentation.
The facility failed to adhere to infection control protocols for a COVID-19 positive resident and a resident with an indwelling urinary catheter. A CNA entered a COVID-19 isolation room without proper PPE and did not perform hand hygiene before interacting with other residents. Additionally, there was no Enhanced Barrier Precautions signage for a resident with a catheter, despite the requirement for such precautions. The DON confirmed the need for proper PPE and signage.
A cognitively impaired resident with a known history of wandering exited the facility without staff knowledge for 40 minutes, resulting in a fall and complaints of head and back pain. The facility failed to provide adequate supervision, did not develop or implement a care plan for the resident's elopement risk, and did not ensure the front door was alarmed or locked.
The facility failed to obtain scheduled medications for two residents, leading to significant health issues. One resident missed his seizure medication for at least two days, resulting in multiple falls, a seizure, and broken ribs. Another resident did not receive prescribed pain medication due to delays in obtaining a signed prescription and issues with the new pharmacy.
The facility failed to prevent verbal/mental abuse when an Activity Assistant made derogatory comments to a male resident with cognitive impairments and an intellectual disability. The resident became upset when he could not go on an outing, and the assistant told him to 'stop crying like a little girl' and 'don't be a baby,' leading to increased distress. The assistant was terminated for unprofessional conduct.
The facility failed to report an allegation of verbal abuse to the State Agency for a resident. Another resident reported that a CNA used inappropriate language towards the resident during the night. The incident was investigated, and the resident in question denied it occurred. No report was made to the State Survey Agency, leading to a deficiency being noted during the survey.
Failure to Thoroughly Investigate Verbal Abuse Allegation and Remove Alleged Perpetrators from Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse, Neglect, Exploitation Policy by not conducting a thorough investigation and not adequately removing alleged perpetrators from resident care after an allegation of verbal abuse. The policy requires immediate investigation of suspected abuse, including identifying and interviewing all involved persons, documenting the investigation, and protecting residents from harm, including room or staffing changes as needed. A moderately cognitively impaired female resident with COPD, anxiety disorder, bipolar disorder, osteoporosis, and generalized muscle weakness reported to the ADON that two CNAs had used foul language toward her and called her a derogatory term. The ADON reported the allegation to the DON, who directed her to notify corporate leadership covering for the Administrator. Corporate staff then interviewed the resident, during which they concluded the situation did not qualify as an abuse allegation after the resident’s account was perceived as changing. They reassigned the two CNAs to a different hallway but did not suspend them, did not document the incident, and did not conduct or document a complete investigation, including interviews of other staff or residents. The resident later reiterated that she had told corporate staff that two CNAs had called her the derogatory term, while both CNAs confirmed they were informed of the allegation and simply reassigned to another hall without being sent home. These actions and omissions demonstrate the facility’s failure to complete a thorough abuse investigation and to fully remove the alleged perpetrators from resident care while the investigation was underway, contrary to its written policy requirements.
Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse by staff to the State Agency as required by its Abuse, Neglect, Exploitation Policy. The policy, dated 1/23/26, states that the facility will report all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but not later than two hours after an allegation involving abuse. On 2/11/26, a resident (R2) reported to the ADON (V3) in the dining room that two CNAs (V6 and V7) had used foul language toward her and called her a c**t. V3 stated she immediately reported the allegation to the DON (V2), who instructed her to report it to corporate staff (V4 and V12), which she did. At the time of the survey on 3/20/26, a review of the facility’s reports to the State Agency showed no documentation that this verbal abuse allegation had been reported. Corporate staff (V4, President of Operations, and V12, Regional Director) confirmed they were covering for the Administrator during the week of the allegation. V12 stated that V2 informed her that R2 claimed two CNAs had called her a c**t and were being mean to her. V4 and V12 then interviewed R2 in an office; V12 reported that R2 changed her story and said no one called her names, but that she did not like the care she was receiving. Based on this, V12 did not believe it qualified as an abuse allegation, and no report was sent to the State Agency. In contrast, during the survey interview on 3/20/26, R2 stated she had told V3 that two CNAs had called her a c**t a few nights prior and that, when questioned later by two older women identified as V4 and V12, she again reported that the CNAs had called her a c**t, though she did not repeat their names because she had already given them to V3. Despite these allegations and the facility’s written policy, the incident was not reported to the State Agency.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Admission Screening
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. One resident, who had a history of hypersexual behavior following a stroke and was not cognitively intact (BIMS score of zero), was admitted to the facility from a hospital where his sexually inappropriate behaviors were documented. Hospital records indicated that the resident had been started on carbamazepine to address hypersexuality, and required interventions such as all-male nursing staff and a video sitter due to persistent inappropriate behaviors. Despite this, the facility's admission screening process did not fully identify or address these risks prior to admission. The facility's administrator later confirmed that, had they been aware of the extent of the behaviors, they would have taken additional precautions or reconsidered the admission. The incident occurred when a staff member observed the resident with his penis exposed, placing it on the lips of another resident who was nonverbal, unable to communicate, and cognitively impaired. The staff member immediately intervened and separated the residents. The victim was particularly vulnerable due to advanced dementia and inability to defend herself. Interviews with facility staff and review of records confirmed that gaps in the admission screening process contributed to the failure to protect the resident from abuse.
Failure to Provide and Document Contracture Prevention and ROM Services
Penalty
Summary
The facility failed to assess, monitor, and implement physician-ordered interventions for a resident with a right-hand contracture. Specifically, the resident had a physician order for a right-hand protector to be applied twice daily to prevent contracture, but the order lacked clear parameters for duration and removal. Observations revealed that the hand protector was not in use, and the resident's right hand was contracted and curled into a fist. There was no documentation in the medical record of any active or passive range of motion (ROM) exercises being performed for the resident's right hand, and the care plan did not address ROM interventions for this condition. Interviews with facility staff indicated a lack of awareness and assessment regarding the use of the hand protector. The MDS nurse confirmed that no quarterly assessments or restorative programs were in place for residents with splints or contractures, and the Assistant Director of Nursing was unaware of the resident's need for a hand protector or who was responsible for its assessment. The facility's policies required maintenance and restorative programs for residents at risk of contractures, but these were not implemented for this resident, who had a history of cerebral infarction, right-hand contracture, and impaired mobility.
Failure to Promptly Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to promptly notify a resident's physician of a significant change in condition, as required by both regulation and facility policy. The resident, who had diagnoses including metabolic encephalopathy, cerebral atherosclerosis, type 2 diabetes mellitus, chronic kidney disease, and Alzheimer's disease, was documented as being severely cognitively impaired. Progress notes indicated that the resident exhibited significant agitation, increased difficulty with gait and balance, and was highly resistant to care. Over the course of two days, the resident's condition declined further, with increased confusion, inability to stand, and repeated episodes of legs giving out during transfers, which was a notable decline from her baseline status. Despite these documented changes, the registered nurse did not notify the resident's physician at the time the changes were observed, instead passing the information along in a shift report. The physician was not informed until after the resident was sent to the hospital and admitted with a urinary tract infection and altered mental status. Both the LPN and the facility administrator confirmed that the physician should have been notified of the change in condition, in accordance with facility policy and regulatory requirements.
Significant Medication Error: Administration of Sulfa Antibiotic to Resident with Documented Sulfa Allergy
Penalty
Summary
A significant medication error occurred when a resident with a documented allergy to sulfa drugs, specifically Sulfasalazine, was administered Sulfamethoxazole-Trimethoprim (Bactrim), an antibiotic containing sulfa. The resident's care plan and Medication Administration Record (MAR) both clearly indicated the sulfa allergy, and the facility's policy required staff to check for allergies before administering medications. Despite these safeguards, the antibiotic was ordered and administered multiple times, even after the pharmacy flagged the allergy and communicated concerns to nursing staff. The resident, who had multiple diagnoses including MRSA UTI, kidney stones, and a history of antibiotic allergy, began receiving the sulfa-containing antibiotic as per physician and nurse practitioner orders. Nursing notes documented the resident's complaints of a sore throat, difficulty swallowing, and the development of a rash after administration of the medication. The allergy was noted in the records, and the pharmacy communicated the risk to the facility, but the medication continued to be given until it was eventually discontinued following further adverse reactions. Interviews with facility staff revealed a lack of appropriate response to the allergy warnings. The nurse practitioner admitted to carrying over the antibiotic order from a hospital consultation and did not consider the allergy significant, while the physician acknowledged that administering the medication was a mistake. The pharmacy confirmed that the allergy was flagged and communicated, but the medication was still dispensed and administered, indicating a breakdown in the facility's medication administration and allergy verification processes.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving a resident to the State Agency, as required by their Abuse, Neglect, and Exploitation Policy. The policy mandates that any suspicion of abuse, neglect, or exploitation must be reported to the State Agency immediately, or within 2 hours if serious bodily injury is suspected, and within 24 hours if not. On January 6, 2025, a resident reported to an Activities Aide that they had been hit by a Certified Nursing Assistant. The Activities Aide informed the Administrator of the allegation. However, the Administrator confirmed that although an investigation was initiated, the alleged abuse was not reported to the State Agency. A review of the past six months of reports to the State Agency confirmed that the incident was not documented as required.
Narcotic Diversion Incident in LTC Facility
Penalty
Summary
The facility failed to prevent the diversion of narcotic medication, specifically Oxycodone, for a resident with multiple medical conditions including quadriplegia, chronic obstructive pyelonephritis, and a history of hip fracture and pressure ulcer. The resident had a physician's order for Oxycodone to manage severe pain, but reported not receiving the medication when needed in early August. The Medication Administration Record (MAR) indicated that the resident did not receive any Oxycodone until August 8, despite having a prescription for it. The investigation revealed that a full card of Oxycodone, delivered on July 30, was missing from the narcotic drawer. The Director of Nursing (DON) and the Administrator were informed, and an investigation was initiated. Video surveillance showed suspicious behavior by a former LPN, who was seen placing something under her jacket and shuffling through papers. The narcotic shift count forms indicated that narcotic medications were not consistently counted by two nurses at shift changes, and there were several days when the narcotics were not counted at all. The facility's investigation included interviews with staff and residents, and it was determined that the missing medication was not accounted for. The pharmacy confirmed the delivery of the medication, but the facility was unable to identify who ordered it due to unidentifiable signatures. The former LPN was suspended and later terminated for not following facility policy and reasonable suspicion of involvement in the missing narcotics. The facility reported the incident to the local police, but there was insufficient evidence for criminal charges.
Failure to Provide Grievance Forms and Procedures
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal by not providing readily available grievance forms and not posting grievance/complaint procedures in prominent locations throughout the facility. This deficiency was identified through observations, record reviews, and interviews, indicating a potential impact on all 89 residents residing in the facility. The facility's policy, dated 5/6/24, requires that notices of residents' rights regarding grievances be posted prominently and that information on how to file a grievance be available to residents, including contact information for the grievance official and expected time frames for grievance resolution. During a resident council meeting, several residents expressed that they were unaware of where or how to file a grievance. A subsequent tour with the Administrator confirmed the absence of posted grievance procedures and readily available grievance forms in the facility. This lack of compliance with the facility's grievance policy and procedure highlights a significant oversight in ensuring residents are informed and able to exercise their rights to file grievances.
Failure to Ensure RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours daily, which is a requirement for the care of the 89 residents residing within the facility. This deficiency was identified through a review of the facility's nurse schedule for the period of August 4 to August 31, 2024. It was documented that the facility did not have RN coverage for at least eight hours on four specific days: August 4, August 11, August 17, and August 18, 2024. The deficiency was confirmed through interviews with the facility's Administrator and the Director of Nursing (DON). The Administrator acknowledged the requirement for eight hours of RN coverage daily, based on the staffing calculator and the number of skilled residents. The DON, who is responsible for scheduling nurses, verified the accuracy of the nursing schedules and confirmed the absence of RN coverage on the specified dates.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for several residents, as observed during a survey. One resident, identified as R62, reported not receiving regular showers or shaves, stating he had not been shaved in over three weeks and had not received his preferred twice-weekly showers for the past month. The resident expressed that staff often cited time constraints or insufficient staffing as reasons for the lack of care. This was corroborated by a Licensed Practical Nurse who confirmed the resident's beard and mustache were unusually long, and the facility's records showed inconsistencies in the bathing schedule. Another resident, R137, had not been shaved since admission to the facility, despite expressing a desire to be shaved. The Director of Nursing confirmed that residents should be shaved on shower days and upon request, even if they are in isolation due to COVID-19. However, documentation for R137's showers was lacking, with only one Skin Monitoring/Shower Review Sheet available, indicating a failure to maintain proper records of care provided. Additional deficiencies were noted with residents R40 and R66. R40, who is moderately cognitively impaired, was observed with long chin whiskers and expressed a preference for assistance with personal grooming, which was not provided. Similarly, R66, who requires assistance with personal hygiene due to physical impairments, had long, jagged fingernails that had not been clipped. A Licensed Practical Nurse confirmed that the resident's nails should have been trimmed, highlighting a lapse in the facility's adherence to its own care policies.
Resident Call Device Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call device was within reach, as required by their policy on call light accessibility and timely response. During an observation, a resident was found sitting in a wheelchair beside his bed, with his call device on the floor near the head of the bed, out of his reach. The resident attempted to retrieve the call device using his cane but was unsuccessful. A Certified Nursing Assistant (CNA) entered the room and confirmed that the call device was indeed out of reach and acknowledged that it should have been accessible to the resident while he was in his room.
Failure to Notify Resident Representatives and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to the hospital to a resident's representative and failed to notify the facility Ombudsman of resident discharges/transfers for three residents. One resident was accepted to a new facility, but the discharge was not documented in the Admission/Discharge Log. Another resident, who experienced shortness of breath and chest pains, requested to return to the hospital, and although the transfer was documented in nursing notes, it was not recorded in the Admission/Discharge Log. Additionally, the facility did not provide written notification of transfer to the hospital for this resident's representative. The facility's Administrator in Training acknowledged that the Discharge Report was being completed incorrectly, and the Ombudsman was not notified of all resident discharges and their reasons. The facility's report submitted to the Ombudsman only included residents who went home and omitted those who were transferred to the hospital. This lack of documentation and notification represents a deficiency in the facility's compliance with regulatory requirements for resident transfers and discharges.
Failure to Provide Bed Hold Policy Documentation
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative when the resident was transferred to a hospital. This deficiency was identified during a review of the clinical records for three residents, specifically for one resident who was hospitalized. The clinical record for this resident did not contain documentation of written notice of the facility's bed hold policy. On a specified date, the facility's administrator was unable to produce any documentation that the bed hold policy was provided to the resident or their representative.
Failure to Supervise Resident on Modified Diet
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident on a mechanically altered diet, as required by their care plan and physician orders. The resident, who has severe cognitive impairment and a history of aspiration pneumonia, was observed eating alone in their room without supervision, despite being on a dysphagia puree texture and honey consistency diet. The Certified Nursing Assistant (CNA) responsible for the resident's care acknowledged the recent dietary change but left the resident unsupervised, contrary to the care plan's directive for meal supervision. The Director of Nursing confirmed that the resident is at risk for choking due to their modified diet and difficulty managing secretions, emphasizing the necessity of supervision during meals. The facility's policies and the resident's care plan clearly state the requirement for supervision to ensure safety during meals, yet this was not adhered to, leading to a deficiency in care. The facility's administrator also recognized the importance of supervising residents on modified diets, highlighting a lapse in following established protocols for meal supervision.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter. The facility's Catheter Care policy, revised on January 24, 2023, mandates that catheter drainage bags be covered with privacy bags and kept off the floor to maintain dignity and prevent contamination. However, observations on August 20, 2024, revealed that a resident's catheter bag was uncovered and the tubing was touching the floor. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the catheter bag should have been covered and elevated. The Director of Nursing (DON) also confirmed that the catheter bags should be covered and not in contact with the floor.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its oxygen policy by not placing oxygen warning signs outside the bedrooms of two residents who were receiving oxygen therapy. One resident, who had a physician order for oxygen at 2 liters per minute due to conditions such as Sleep Apnea and Chronic Obstructive Pulmonary Disease, was observed without the required signage on their door. Another resident was also found to be receiving oxygen without any signage, and there was no physician order documented for their oxygen use or care. The Director of Nursing confirmed that signage should be present and that a physician order is necessary for oxygen use. Additionally, the facility did not follow its policy regarding the maintenance of oxygen equipment for another resident. The resident's nebulizer tubing and mask were found on the nightstand, undated and unbagged, despite the policy requiring weekly changes and proper storage when not in use. A Licensed Practical Nurse confirmed the oversight, noting that the equipment had not been changed since the previous week and was not stored correctly.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to provide adequate documentation of collaboration between the facility and the dialysis center for a resident receiving dialysis. The facility's dialysis policy requires nursing staff to report the resident's condition and treatment provisions to the dialysis provider each treatment day and to obtain a report upon the resident's return from dialysis. However, the clinical record for the resident, who receives dialysis three times a week, did not include any dialysis communication forms for a period from July 20, 2024, to the current date. Only two communication forms were provided for dates in early and mid-August 2024. The facility administrator confirmed the absence of additional required documentation.
Infection Control Deficiencies in PPE Usage and Signage
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed for a resident diagnosed with COVID-19. A Certified Nursing Assistant (CNA) entered the room of a COVID-19 positive resident wearing only a gown and surgical mask, without the required N95 mask, gloves, or eye protection. After removing the gown, the CNA did not perform hand hygiene before continuing to deliver meal trays to other residents, which was against the facility's COVID-19 Prevention, Response, and Reporting policy. The Director of Nursing confirmed that staff should wear an N95 mask, eye protection, gown, and gloves when entering a COVID-19 isolation room and perform hand hygiene upon exiting. Additionally, the facility did not post Enhanced Barrier Precautions signage for a resident with an indwelling urinary catheter. The resident's room lacked the necessary signage to alert staff and visitors of the required precautions, despite the presence of red isolation bins and the resident being listed on the facility's Enhanced Barrier Precautions list. A Licensed Practical Nurse confirmed the absence of signage and acknowledged that it should have been posted. The Director of Nursing stated that for residents on Enhanced Barrier Precautions, a sign should be posted, and staff should wear a gown, gloves, and mask when providing care.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and did not develop or implement a care plan for a resident at risk for wandering and elopement. This resulted in a cognitively impaired resident with a known history of wandering exiting the facility without staff knowledge for 40 minutes. The resident was found outside the facility, having fallen in the mud and complaining of head and back pain. The facility is located near a busy four-lane road, increasing the risk of serious harm to the resident. The resident's care plan documented that they were an elopement risk and had impaired cognition, requiring assistance with decision-making. Despite this, the resident did not wear an alarm to prevent elopement, and the front door was not alarmed or locked when the receptionist left early. The resident had previously exhibited exit-seeking behavior and had been placed on 1:1 observation for safety, but this was not consistently maintained. On the night of the incident, the resident was able to leave the facility through the front door, which was not locked or alarmed, and was found outside 40 minutes later. Interviews with staff revealed that there was confusion and inconsistency in monitoring the resident. The Licensed Practical Nurse (LPN) on duty initiated 15-minute checks but was unable to consistently monitor the resident due to being the only nurse on duty for two halls. The receptionist did not lock or alarm the front door when leaving early, and there was no formal documentation of the 15-minute checks. The facility's failure to provide adequate supervision and implement effective interventions for the resident's elopement risk led to the resident's unsupervised exit and subsequent fall.
Removal Plan
- Reassessment of all residents for wander risk assessment by V27, Assistant Director of Nursing
- At risk residents for wandering/elopement had care plans reviewed and updated with safety measures and interventions by V28, Care Plan Coordinator
- Updated safety measures and interventions were added to Kardex by V28, Care Plan Coordinator
- Re-education on elopement policy and procedure as well as Identifying the signs and symptoms of wandering by V2, Director of Nursing
- Re-educate on the facility policy and procedure regarding elopement by V2, Director of Nursing
- Document Performance Improvement Plan/PIP implementation, PIP progress, and Quality Assurance Agency/QAA Committee Meeting Minutes where PIP is discussed by V2, Director of Nursing
Failure to Provide Scheduled Medications
Penalty
Summary
The facility failed to obtain scheduled medications from the pharmacy for two residents, resulting in significant health issues. One resident, who had a history of generalized idiopathic epilepsy, did not receive his prescribed seizure medication, Keppra, for at least two days. This lapse led to the resident experiencing multiple falls, a seizure, and ultimately breaking three ribs. The resident's medical records and progress notes indicated that the medication was on order but not available, and the facility staff were aware of the issue but did not take adequate steps to resolve it promptly. The resident's condition deteriorated, necessitating an emergency room visit where it was confirmed that his Keppra levels were critically low, and he had sustained rib fractures from the falls. The facility's Director of Nursing and other staff members acknowledged the problem but failed to secure the medication in a timely manner, despite multiple communications with the pharmacy. The pharmacy records corroborated that the medication was requested but not refilled due to a perceived early refill request, and the facility did not utilize alternative means to obtain the medication. Another resident, who was prescribed Norco for pain management, also did not receive the medication as scheduled due to issues with obtaining a signed prescription and delays from the new pharmacy. This resident's medical records showed multiple entries indicating the medication was not available, and the facility staff confirmed the delay in providing the necessary pain relief. The facility's failure to provide these essential medications as prescribed resulted in significant discomfort and health risks for the residents involved. The Immediate Jeopardy was identified when the first resident fell and broke three ribs due to the lack of seizure medication, highlighting the severe impact of the facility's deficiencies in pharmaceutical services.
Removal Plan
- Audit of all resident's receiving seizure medications by Pharmacy.
- Resident's receiving seizure medications the medication is in house and being administered per the physician order by V2, Director of Nursing.
- All nursing staff have access to the backup medication machine by V2, Director of Nursing.
- Re-education on medication administration and contacting physician and pharmacy if medication is not available by V2, Director of Nursing.
- Document Performance Improvement Plan/PIP implementation, PIP progress, and Quality Assurance Agency/QAA Committee Meeting Minutes where PIP is discussed by V1, Administrator in Training.
Staff-to-Resident Verbal Abuse Incident
Penalty
Summary
The facility failed to prevent staff-to-resident verbal/mental abuse for one resident (R11) of four residents reviewed for abuse. The incident occurred when V25, an Activity Assistant, made a derogatory comment to R11, a male resident with mild to moderate cognitive impairments and an intellectual disability, who was also admitted to hospice care. R11 became upset when he could not go on an activity outing, and V25 responded by telling him to 'stop crying like a little girl' and 'don't be a baby.' This interaction was overheard by V23, the Therapy Director, and other residents and staff present in the dining room. V25 admitted to making the comment, which led to R11 becoming more tearful. The facility's policy on abuse, neglect, and exploitation clearly states that residents must not be subjected to abuse, including verbal and mental abuse, by anyone, including facility staff. The incident was documented in a state report and a summary of the investigation, which concluded that V25's actions constituted unprofessional conduct. V25 was subsequently terminated from employment. The facility's policy defines verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families. Mental abuse includes humiliation, harassment, threats of punishment, or deprivation. The report indicates that V23, the Therapy Director who witnessed the incident, is no longer employed with the facility.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Agency for one resident (R5) out of a sample of 17 residents reviewed for abuse. According to the facility's policy on abuse, neglect, and exploitation, any suspicion or report of abuse must be immediately reported to the administrator and other officials, including the State Survey Agency. The incident in question involved a report from another resident (R16) who claimed that a CNA (V29) had used inappropriate language towards R5 during the night. This report was investigated by the Administrator-In-Training (V1) and the Regional Nurse Consultant (V17). However, R5 denied that the incident occurred, and V1 concluded that there was no allegation of abuse to report, citing R5's history of false allegations and interjecting in other residents' care. Consequently, no initial or five-day report was made to the State Survey Agency regarding the allegation of verbal abuse by V29 to R5. The facility's failure to report the allegation of verbal abuse was based on the denial by R5 and the history of the resident who reported the incident. Despite the facility's policy requiring immediate reporting of any allegations or suspicions of abuse, the decision was made not to report the incident to the State Survey Agency. This inaction led to a deficiency being noted during the survey, as the facility did not comply with the mandated reporting requirements. The report highlights the importance of adhering to established procedures for reporting abuse, regardless of the perceived credibility of the allegation or the history of the residents involved.
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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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