Loft Rehab Of Rock Springs, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Decatur, Illinois.
- Location
- 2530 North Monroe Street, Decatur, Illinois 62526
- CMS Provider Number
- 146003
- Inspections on file
- 69
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Loft Rehab Of Rock Springs, The during CMS and state inspections, most recent first.
A resident with multiple chronic and psychiatric conditions was found to be living in a room with significant dust on a bookcase and model cars, cobwebs and dust on the windowsill and around a decorative light, and a trashcan that had reportedly not been emptied for several days. The resident stated housekeeping only comes every two or three days and does not clean well, and the housekeeping supervisor acknowledged the department is understaffed and rooms are not cleaned appropriately, contrary to the facility’s written policy requiring routine cleaning and disinfection of resident rooms.
Two residents with complex medical and cognitive conditions were involved in a physical altercation over a personal belonging, resulting in one resident sustaining a bruise. The incident, which was confirmed by both residents and documented in facility records, occurred despite an existing care plan addressing physical aggression and the facility's policy to prevent abuse.
Thirteen residents were found to be living in rooms with ceiling tiles in disrepair, visible black substance resembling mold, and persistent bathroom cleanliness issues. Staff interviews confirmed ongoing maintenance problems and unaddressed environmental hazards, with both housekeeping and administration acknowledging the deficiencies.
A resident who was cognitively impaired and dependent on staff for mobility developed a pressure ulcer that worsened over time due to the facility's failure to consistently implement pressure-relieving interventions, such as use of a low air loss mattress, and to timely revise the treatment plan despite ongoing deterioration and infection. Staff interviews confirmed lapses in following prescribed interventions and a lack of expertise in advanced wound care therapies.
A resident with a right humerus fracture experienced a six-day delay in receiving an orthopedic consult due to the facility's failure to implement a STAT order. Despite severe pain and swelling, the resident was not seen by a specialist until six days after the fall, during which time increased doses of Tramadol were required for pain management. The delay was due to a lack of communication regarding the urgency of the situation.
Two residents in an LTC facility suffered injuries due to inadequate fall interventions. One resident, with hemiplegia, fell twice from bed, hitting her head on a dresser due to missing safety measures like a scoop mattress and fall mats. Another resident, with multiple health issues, fractured her arm during assisted ambulation when her foot got stuck on a damaged threshold strip. The assisting CNA, who was pregnant, did not use a gait belt and could not provide adequate support. The facility failed to maintain safety protocols, contributing to these incidents.
A resident's medical records were found to be inaccurate and incomplete, with discrepancies in Tramadol administration documentation and missed pain assessments. Additionally, a physician's order for a sling was not timely transcribed, and a leg wound dressing change was incorrectly signed off as completed. The DON acknowledged these documentation errors, which contravened the facility's policy for accurate and timely record-keeping.
A resident with multiple medical conditions, including a fracture and cellulitis, did not receive a requested shower and wound dressing change before a doctor's appointment due to communication breakdowns among staff. The resident, who has no cognitive impairment, was not informed of her shower schedule and relied on a specific CNA who was unavailable. The facility's shower schedule was based on room numbers, and the resident's preferences were not documented or communicated effectively, leading to a deficiency in honoring resident rights.
A staff member refused to assist a resident with impaired vision and coordination issues during a toileting hygiene request, leading to a deficiency in protecting the resident from verbal abuse. The resident, who required assistance due to medical conditions, was left to clean himself after an incontinent episode, which was against the facility's policy on abuse and neglect.
A resident, dependent on staff for bathing, did not receive a requested shower and wound dressing change before a doctor's appointment. Despite being scheduled for showers, the resident was unaware of her shower days and relied on a specific CNA who was unavailable. The facility's bath schedule lacked clarity, and the Director of Nursing was unaware of the resident's unmet requests. The resident's nurse confirmed the dressing change was not completed, indicating a breakdown in communication and care coordination.
The facility failed to provide a sufficient supply of towels and washcloths, impacting residents' care. A resident reported missed showers due to linen shortages, and a CNA confirmed frequent shortages in the linen cart and closet. The laundry department struggled with staffing and budget cuts, reducing shifts from three to two, which hindered the ability to maintain adequate linen supplies. The administrator was aware of the issue but had not ordered more linens, affecting all 104 residents.
The facility failed to ensure cleanliness and repair in utility rooms and nurses stations, affecting all 105 residents. Inspections revealed issues such as a leaking sink, black substance under cabinets, and accumulated dirt and debris in utility rooms. The maintenance director confirmed awareness of the issues, and the President of Clinical Services noted neglect in cleaning duties.
The facility failed to have an RN on duty for eight consecutive hours per day, as required. During an investigation, it was found that on several dates in November 2024, no RN was scheduled to provide direct care. Interviews confirmed that the RNs present, including the Assistant Directors of Nursing, did not work on the floor for the required duration, impacting the care of all 108 residents.
The facility failed to employ a certified Dietary Manager, affecting all 108 residents. The current manager is not certified and has not completed the necessary course, yet is responsible for managing the dietary department, including regulatory oversight and staff training. This was confirmed by both the manager and the facility's administrator.
The facility failed to provide adequate support personnel for the food and nutrition service, affecting 108 residents. The dietary manager was observed managing kitchen personnel and acting as a cook due to insufficient staffing. The schedule showed only two staff members were available on several days, which the dietary manager confirmed was inadequate for timely completion of essential functions.
The facility did not adhere to the posted lunch menu, serving pork chops instead of pork loin, sliced bread instead of a dinner roll, and apple slices with cinnamon instead of apple cobbler. A resident noted frequent menu substitutions, and complaints were documented by the administrator and in resident council minutes. This issue potentially affects all 108 residents.
The facility failed to ensure a clean and safe environment for residents, with multiple rooms found cluttered and unclean, and walls in disrepair. Residents expressed dissatisfaction with housekeeping services, and staff confirmed that cleaning standards were not met. The facility's cleaning policy was not adhered to, contributing to the deficiency.
A resident with intact cognition physically abused another resident with multiple diagnoses, including Mild Intellectual Disability and Traumatic Brain Injury, in the dining room. The incident occurred despite the facility's policy against abuse, and the affected resident immediately complained of pain. A CNA witnessed the event, confirming the abuse.
Two residents with pressure ulcers did not receive prescribed nutritional supplements and wound treatments due to time constraints and supply issues. A resident with a stage four sacral ulcer was not given Arginaid, a protein supplement, and missed several wound treatments. Another resident also missed multiple wound treatments for ulcers on the sacrum and shoulder. The DON confirmed these deficiencies.
The facility failed to have physician orders for oxygen use for three residents who required oxygen therapy. The residents' care plans lacked specific details for oxygen delivery, and there were no documented physician orders for oxygen administration, despite the facility's policy requiring such orders.
The facility failed to provide sufficient RN hours on two of sixteen days reviewed, with zero hours of RN coverage on two specific days. This was confirmed by the facility's Nursing Schedule and an interview with the Administrator. At the time, the facility had 95 residents.
Failure to Maintain Cleanliness in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and homelike environment for one resident. The resident, admitted on 4/9/2016, has multiple documented diagnoses including personal history of COVID-19, age-related nuclear cataract, homonymous bilateral field defects (right side), cerebral infarction, hyperlipidemia, essential (primary) hypertension, major depressive disorder (single episode), bipolar disorder (current episode manic without psychotic features, moderate), anxiety disorder, vitamin deficiency, intermittent explosive disorder, nicotine dependence, alcohol abuse, and obsessive-compulsive disorder. During an observation on 03/09/26 at 10:45 AM, the resident’s room contained a black bookcase shelving unit with model cars and shelves covered in dust. The windowsill had cobwebs and dust extending from plant containers to the sill, as well as cobwebs surrounding a decorative light in the windowsill. At the same time, the resident reported that housekeeping comes to clean the room every two or three days but does not clean very well. The resident lifted a half-full trashcan and stated the trash had not been emptied for three days, and pointed to the windowsill, stating it had been dirty for a long time. On 03/10/26 at 9:44 AM, the Housekeeping Supervisor stated that the housekeeping department is understaffed and that resident rooms are not cleaned appropriately. The facility’s “Room Change Cleaning and Disinfection” policy dated 5/21/2021 states that it is the facility’s policy to ensure routine cleaning and disinfection to provide a safe, sanitary environment, including routine cleaning and disinfection of frequently touched or visibly soiled surfaces in resident rooms. The observed conditions and staff statements show that this policy was not being followed for this resident’s room.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, as evidenced by a documented physical altercation between two individuals. One resident, who had diagnoses including End Stage Renal Disease, Chronic Diastolic Heart Failure, Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Stage Five Chronic Kidney Disease, reported being grabbed and punched in the arm by her roommate during a dispute over a shirt. The resident sustained a bruise on her arm as a result of the incident and responded by hitting the other resident back and throwing a glass of water in an attempt to stop the altercation. The other resident involved, who had moderate cognitive impairment and diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Hyperlipidemia, and COPD, also confirmed the altercation but denied being harmed. The incident was corroborated by interviews and record reviews, which indicated that the altercation was initiated over a personal belonging and escalated to physical violence. The care plan for the resident with cognitive impairment had previously addressed physical aggression towards other residents. The facility's abuse policy requires protections to prevent abuse, neglect, and exploitation, including resident-to-resident altercations, but the occurrence of this event demonstrates a failure to prevent physical abuse between residents.
Failure to Maintain Clean and Hazard-Free Environment
Penalty
Summary
The facility failed to maintain a clean and hazard-free environment for thirteen out of nineteen residents reviewed for physical plant problems. Observations revealed that multiple resident rooms, including those on the fourth floor, had ceiling tiles in disrepair with a raised black substance resembling mold, as well as dirty sprinkler heads and vents. In one resident's room, the bathroom toilet had a persistent dark ring and sediment that housekeeping staff were unable to remove, despite repeated cleaning attempts and reporting the issue to maintenance and supervisory staff. The maintenance director confirmed the presence of the black substance on ceiling tiles in several rooms, and the housekeeper stated that the toilet issue had not been addressed despite being reported. Interviews with staff indicated ongoing issues with the maintenance department and acknowledged that the cleanliness of the building was suboptimal. The DON noted that maintenance had been inconsistent, and the administrator was unaware of the extent of the environmental hazards, including the raised black substance on ceiling tiles in resident rooms. Residents also reported missing ceiling tiles, chipping paint, and the presence of a black substance in their rooms and bathrooms during their stay.
Failure to Implement and Monitor Pressure Ulcer Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement and monitor pressure-relieving interventions and did not re-evaluate the effectiveness of pressure ulcer treatment for a resident at risk for pressure ulcers. The resident, who was cognitively impaired and dependent on staff for mobility, was admitted without pressure ulcers but developed an unstageable pressure ulcer to the coccyx shortly after admission. The care plan and physician orders specified the use of a low air loss mattress and regular repositioning, but these interventions were not consistently implemented, as evidenced by the resident being observed on a standard mattress after a room change. Despite ongoing wound assessments documenting worsening of the pressure ulcer, including progression from unstageable to stage 4 with increased size, tunneling, and drainage, the treatment plan was not revised in a timely manner. The wound continued to deteriorate over several weeks, with repeated documentation of heavy drainage, necrotic tissue, and infection. The wound care provider continued the same treatment orders for extended periods, even as the wound failed to improve and new complications developed. Staff interviews confirmed that the resident was not on the prescribed low air loss mattress due to a room change, and the wound care nurse acknowledged a lack of familiarity with negative pressure wound therapy, which may have been beneficial given the wound's condition. Facility leadership stated that they would expect a change in treatment after two weeks without progress, but this did not occur, contributing to the ongoing decline of the resident's pressure ulcer.
Delayed Orthopedic Consult for Fractured Humerus
Penalty
Summary
The facility failed to implement a physician's STAT order for an orthopedic consult appointment in a timely manner for a resident with a right humerus fracture. This resulted in a six-day delay before the application of a cast, causing the resident severe pain and swelling. The resident, who had no cognitive impairment, fell and sustained a fracture on 2/18/2025, but was not seen by an orthopedic specialist until 2/24/2025. After the fall, the resident was assessed by a nurse practitioner who ordered immediate X-rays, which confirmed an acute transverse fracture with modest displacement. Despite the physician's order for an immediate orthopedic consultation, the facility scheduled the resident's appointment for 2/24/2025, six days after the fall. During this period, the resident experienced significant pain and swelling, requiring increased doses of Tramadol for pain management. The delay in treatment was attributed to the facility's failure to communicate the urgency of the situation to the orthopedic office. The orthopedic nurse practitioner expressed frustration upon seeing the resident, noting the lack of proper arm stabilization and the significant swelling. The facility's Director of Nursing acknowledged the oversight and the need for immediate action, which was not taken, resulting in prolonged discomfort for the resident.
Failure to Implement Fall Interventions Leads to Resident Injuries
Penalty
Summary
The facility failed to provide a safe environment and implement effective fall interventions for two residents, resulting in significant injuries. One resident, diagnosed with hemiplegia and other conditions, fell out of bed twice, hitting her head on a bedside dresser, which led to head lacerations requiring emergency medical attention and staples. The facility did not maintain the necessary safety interventions, such as a scoop mattress, fall mats, and proper bed positioning, which contributed to these incidents. Additionally, the bedside dresser was not kept at a safe distance from the bed, despite previous instructions to do so. Another resident, with multiple medical conditions including morbid obesity and diabetes, sustained a right arm fracture during an assisted ambulation to the bathroom. The assisting CNA, who was pregnant, did not use a gait belt and was unable to provide adequate support when the resident's foot got stuck on a damaged metal threshold strip. The resident's request for assistance to free her foot was not met, leading to a fall that resulted in a fracture. The facility's failure to repair the hazardous threshold strip and ensure proper use of gait belts during transfers contributed to the incident. Interviews with staff and residents highlighted the lack of adherence to safety protocols and the absence of necessary interventions. The facility's policies required specific measures to minimize fall risks, but these were not consistently implemented, leading to preventable injuries. The staff's lack of awareness and failure to maintain safety interventions were significant factors in the deficiencies observed.
Inaccurate and Incomplete Medical Records for a Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, identified as R1, who was reviewed for documentation. R1's medical records showed inconsistencies and omissions in the documentation of medication administration and pain assessment. Specifically, there was a discrepancy between the number of Tramadol doses recorded as removed from the narcotic supply and the number documented as administered in the Medication Administration Records (MAR). Additionally, the facility did not consistently document R1's pain levels as required, with 61 out of 90 opportunities missed. Further issues were identified with the documentation of a physician's order for a sling for R1's right upper extremity following a fall. The order was not transcribed to R1's Physician Order Sheets (POS) or MAR in a timely manner, resulting in a five-day delay. The sling was documented as discontinued on the same day it was finally added to the MAR, and there was no signature to confirm its application. This lack of documentation accuracy extended to a leg wound dressing change, which was signed off as completed despite the resident confirming it was not done on the specified date. The Director of Nursing acknowledged the documentation errors, noting that the nurses failed to record the necessary information accurately. The facility's policy on medical record documentation emphasizes the need for complete, accurate, and timely documentation to reflect the resident's experiences and progress. However, the observed deficiencies indicate a failure to adhere to these standards, resulting in incomplete and inaccurate medical records for R1.
Failure to Honor Resident's Right to Choose Shower and Wound Care Schedule
Penalty
Summary
The facility failed to honor a resident's right to choose when to have a shower and when to have a wound dressing changed, affecting one resident. The resident, who has a BIMS score indicating no cognitive impairment, expressed a preference for having her leg dressing changed after a shower before a doctor's appointment. However, the resident did not receive a shower or a dressing change as requested. The resident reported that she had not been informed of her shower schedule and had to rely on a specific CNA, who was not on duty, to accommodate her requests. The resident's medical conditions include a displaced fracture, cellulitis, hypertension, atrial fibrillation, anemia, diabetes, and morbid obesity, requiring daily wound care. Despite the resident's clear communication of her needs to the staff, there was a breakdown in communication among the staff members. The LPN on duty was not informed of the resident's request for a shower and dressing change before her appointment, and the CNA who usually assisted the resident was not present due to a call-off. The facility's shower schedule was based on room numbers, and the resident's preference for a different schedule was not documented or communicated effectively. The Director of Nursing and other staff members were unaware of the resident's unmet requests, indicating a lack of coordination and communication within the facility. This failure to accommodate the resident's preferences and ensure her care needs were met resulted in a deficiency in honoring resident rights.
Failure to Assist Resident with Toileting Hygiene
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when a staff member, identified as V12, refused to assist a resident, R4, with a requested transfer, ambulation, and toileting hygiene. R4, who was admitted to the facility with medical conditions including post-procedural partial obstruction of the colon, ataxia, and dizziness, required assistance for transfers and ambulation due to impaired vision and coordination issues. On the day of the incident, R4 experienced bowel incontinence and requested help from V12 to get cleaned up. However, V12 refused to assist, telling R4 that he could clean himself, and left the room, which was witnessed by another staff member, V11. R4 reported feeling unsteady and needing assistance to balance when standing and walking, but V12 did not provide the necessary help. Instead, V12 placed R4's cane beside him and left, returning only after R4 activated the call light multiple times. The facility's policy on abuse, neglect, and exploitation defines abuse as the deprivation of services needed for residents to attain the highest physical, mental, and psychological well-being, and neglect as the failure to provide necessary services to avoid physical harm, mental anguish, or emotional distress. The administrator, V1, acknowledged the incident as abusive and terminated V12's employment.
Failure to Provide Scheduled Shower and Dressing Change
Penalty
Summary
The facility failed to provide a dependent resident with a shower and wound dressing change prior to a doctor's appointment. The resident, who has a history of a displaced transcondylar fracture of the right humerus, weakness, and cellulitis of both lower limbs, is totally dependent on staff for bathing and showers. Despite requesting a shower and dressing change before a scheduled doctor's appointment, the resident did not receive these services. The resident expressed that she had not been informed of her scheduled shower days and had not been offered a shower since returning to the facility in January. She relied on a specific CNA, who was not on duty, to provide her showers, indicating a lack of communication and scheduling issues within the facility. The facility's bath schedule only documented the resident's shower days by room number, and there was no record of the resident receiving a shower on her scheduled days. The Director of Nursing was unaware of the resident's unmet requests and stated that showers are provided based on room number unless residents prefer another time. The CNA familiar with the resident confirmed that she was not on duty the day the resident requested a shower, which likely contributed to the oversight. The resident's nurse also confirmed that the leg dressing change was not completed before the appointment, highlighting a breakdown in communication and care coordination among the staff.
Linen Shortage Affects Resident Care
Penalty
Summary
The facility failed to maintain an adequate supply of towels and washcloths, impacting the residents' right to a clean, comfortable environment and quality of care. Observations and interviews revealed that residents often had to wait for showers due to a lack of available linens. A resident reported that there were times when showers could not be given because there were no towels or washcloths available. A CNA confirmed that the linen cart and closet frequently lacked necessary items, and the Director of Nursing acknowledged that linen shortages were a known issue. The laundry department struggled to keep up with the demand due to staffing shortages and budget cuts. The facility had reduced from three shifts to two, making it difficult to maintain an adequate supply of clean linens. The laundry aide reported that the workload had increased, and the facility had been running behind on laundry for about a month. The administrator was aware of the issue but had not yet ordered additional linens. The deficiency affected all 104 residents in the facility, as the lack of towels and washcloths hindered the ability to provide timely and adequate personal care.
Facility Fails to Maintain Cleanliness and Repair in Utility Rooms
Penalty
Summary
The facility failed to maintain cleanliness and repair in utility rooms and nurses stations, potentially affecting all 105 residents. During an inspection, the housekeeping supervisor, V8, revealed that the housekeeping staff were responsible for daily cleaning of these areas. However, upon inspection, the 3rd floor soiled utility room was found with a sink and cabinet detaching from the wall, a black substance covering the cabinet floor, and water leaking into the under-sink compartment. The maintenance director, V9, confirmed awareness of the issue and acknowledged a maintenance request had been submitted two weeks prior. Further observations revealed that the 3rd and 4th floor clean utility rooms had accumulated dirt and debris, indicating they had not been cleaned for a significant period. The 4th floor soiled utility room had a sink with missing caulking, a disrepair backsplash, and a discolored floor with dirt and debris. Additionally, the baseboards and toe kick boards around the fourth floor nurses station were dirty and appeared neglected. The President of Clinical Services, V5, confirmed these findings and noted that the facility employed a full-time floor person who seemed to be neglecting their duties.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours per day, as required. This deficiency was identified during an investigation conducted on November 25 and 26, 2024, where it was observed that no RN was providing direct care to residents during the specified hours. The facility's staffing sheets for November 2024 confirmed that an RN was not scheduled for several dates, including November 11, 12, 15, 16, 17, 20, 21, and 25. The Assistant Directors of Nursing, identified as V13 and V14, were noted on the staffing sheets but did not provide direct care for the required duration. Interviews with the facility's Director of Nursing (DON) and Assistant Directors of Nursing revealed that the RNs present in the facility, including V13 and V14, did not work on the floor providing direct care to residents. V13 confirmed that she only spent about an hour on the floor per day and primarily worked in her office. The DON acknowledged that on the specified dates, no RN provided direct care for eight consecutive hours, affecting the care of all 108 residents residing in the facility.
Unqualified Dietary Manager in Facility
Penalty
Summary
The facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 108 residents residing in the facility. On multiple occasions, it was observed and confirmed through interviews that the current Dietary Manager, identified as V3, is not certified and has not completed the Certified Dietary Manager Course. Despite this, V3 is actively managing all aspects of the dietary department, including regulatory oversight related to safe food handling, managing kitchen personnel, and training newly hired staff. The facility's administrator, identified as V1, confirmed that V3 is not certified, and the dietary personnel schedule also lists V3 as the Dietary Manager.
Insufficient Dietary Staffing in LTC Facility
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service, potentially affecting all 108 residents. The dietary manager, responsible for managing all aspects of the dietary department, including regulatory oversight and staffing, was observed actively managing kitchen personnel and directing food sanitation and preparation activities. Due to a lack of support personnel, the dietary manager was also acting as a cook. The dietary personnel schedule provided by the administrator showed that only two staff members were scheduled to perform essential dietary services on several days, which the dietary manager confirmed was insufficient to complete essential functions in a timely manner.
Failure to Follow Posted Menus
Penalty
Summary
The facility failed to adhere to the posted and printed menus, which are required to meet the nutritional needs of residents. On the specified date, the lunch menu was supposed to include Herb Roasted Pork Loin, Candied Sweet Potatoes, Buttered Cabbage, Apple Cobbler, and a Dinner Roll. However, observations revealed that a pork chop was served instead of pork loin, sliced bread was provided instead of a dinner roll, and apple slices with cinnamon were served in place of apple cobbler. The dietary manager, V3, acknowledged the substitution of pork chops due to the unavailability of pork loin from the vendor. Interviews and record reviews further highlighted the issue, with a resident, R4, stating that the kitchen frequently makes substitutions and does not follow the posted menu. The facility's administrator provided a complaint form and resident council minutes indicating dissatisfaction with the menu adherence. The dietary manager confirmed the menu for the day and acknowledged the substitutions made. This failure to follow the menu has the potential to affect all 108 residents in the facility.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations, interviews, and record reviews. Multiple resident rooms were found to be cluttered and unclean, with piles of personal items, trash, and food debris. Specific instances included a room with piles of unfolded blankets and full trash bags, another with empty cups and candy wrappers, and a room with cases of tea and food items obstructing pathways. Additionally, the walls in some rooms were scuffed and had chipping paint. The Resident Council Meeting minutes from several months indicated ongoing dissatisfaction with housekeeping services, with residents expressing a desire for better cleaning and less complaining from staff. Interviews with facility staff, including the Director of Nursing and the Director of Housekeeping, confirmed that the housekeeping staff were not meeting the expected standards for room cleanliness. The Director of Housekeeping outlined the cleaning responsibilities, which included sweeping, mopping, and wiping down surfaces, but acknowledged that these tasks were not being adequately performed. The Maintenance Director also confirmed the need for repairs and painting of the walls in resident rooms. The facility's policy on room cleaning and disinfection emphasized routine cleaning and attention to high-touch areas, which was not being adhered to, contributing to the deficiency.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, affecting two residents. The incident occurred in the facility dining room when one resident, who has intact cognition, struck another resident in the face/temple area. The resident who was struck has a diagnosis of Mild Intellectual Disability, Schizophrenia, Weakness, Seizure Disorder, and Traumatic Brain Injury, and is completely dependent on or requires substantial staff assistance for activities of daily living. This resident was seated in a wheelchair and was mumbling, which was usual behavior, when the other resident wheeled over and punched them. The facility's policy on Abuse, Neglect, and Exploitation clearly states that each resident has the right to be free from abuse by anyone, including other residents. Despite this policy, the incident occurred, and the affected resident immediately complained of face pain after being struck. A Certified Nurse Aide present during the incident confirmed the sequence of events, noting that the resident who was struck stated that they had been hit. This incident highlights a failure in the facility's responsibility to protect residents from abuse by other residents.
Failure to Administer Nutritional Supplements and Wound Treatments
Penalty
Summary
The facility failed to provide nutritional supplements and wound treatments as ordered for two residents with pressure ulcers. One resident, identified as R1, had a stage four pressure ulcer on the sacrum and was prescribed Arginaid, a protein nutritional supplement, to aid in wound healing. Despite the order being placed in early April, the supplement was never received or administered to R1. Additionally, R1's prescribed wound treatments, including the application of Gentamicin Sulfate Cream and other dressings, were not consistently completed due to time constraints, as documented by the LPN responsible for the care. Another resident, R3, also did not receive prescribed wound treatments for pressure ulcers on the sacrum and right shoulder. The treatment records indicate multiple instances where the treatments were not completed, again due to time constraints as stated by the LPN. The Director of Nursing confirmed these deficiencies, acknowledging that the treatments were not administered as ordered for both residents.
Lack of Physician Orders for Oxygen Use
Penalty
Summary
The facility failed to have physician orders for oxygen use for three residents (R1, R2, and R5) who were reviewed for oxygen administration. The facility's Oxygen Administration policy requires oxygen to be administered under physician orders, except in emergencies, and mandates specific care plan details for oxygen therapy. However, R1's care plan did not specify the oxygen delivery system, flow rate, or frequency, and there was no physician order for oxygen administration in R1's Order Summary Report. R1, who has diagnoses of Heart Failure and COPD, stated that they used oxygen as needed while residing at the facility. The Director of Nursing confirmed that there should be a physician's order for oxygen use and that the care plan should specify the necessary details for oxygen therapy. Similarly, R2's Order Summary Report did not document an order for oxygen administration despite R2 being cognitively intact and using oxygen. R2's Practitioner Progress Note indicated the need for continued oxygen use, and R2 was observed wearing oxygen at 2 liters per minute. R5, who was admitted to the facility and later discharged to an acute care hospital, also did not have an admission order for oxygen despite having discharge orders from the hospital for continuous oxygen use. The Assistant Director of Nursing confirmed that R5 was wearing oxygen upon admission and during their stay at the facility, but no admission orders for oxygen were listed in the medical record.
Insufficient RN Coverage
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on two of sixteen days reviewed for RN staffing. Specifically, on 5/3/24 and 5/5/24, the facility scheduled zero hours of RN coverage for a 24-hour period. This deficiency was confirmed by the facility's Nursing Schedule document and an interview with the Administrator, who verified the accuracy of the schedule. At the time of the deficiency, the facility had 95 residents, as documented in the Resident Midnight Census dated 5/6/24.
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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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