Manor Court Of Freeport
Inspection history, citations, penalties and survey trends for this long-term care facility in Freeport, Illinois.
- Location
- 2170 West Navajo Drive, Freeport, Illinois 61032
- CMS Provider Number
- 146102
- Inspections on file
- 38
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Manor Court Of Freeport during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia was found in bed with a pillow over her face while her severely cognitively impaired roommate, who has Alzheimer’s disease and a history of nighttime wandering, was standing over her. Two CNAs discovered the situation during a bed check, removed the pillow, and took the standing resident from the room; the resident in bed did not initially appear distressed but became agitated when awakened before calming after reorientation. The CNAs reported difficulty finding a nurse and each believed another staff member was reporting the event, leading to a significant delay before the Memory Care Director, DON, and administrator were notified, despite facility policy requiring immediate reporting of alleged abuse.
A resident with dementia and severe cognitive impairment was found in bed with a pillow over her face and her severely cognitively impaired roommate standing over her, after the roommate had been wandering and redirected back to the room. Two CNAs discovered the situation during a bed check, removed the pillow, and separated the residents, but did not immediately report the incident to nursing staff or appropriate authorities. Subsequent staff coming on shift were not informed of the event, and leadership only learned of it later that day, despite a facility abuse policy requiring immediate reporting of alleged abuse.
A resident with dementia, impaired mobility, and identified risk for pressure ulcers did not receive consistent, documented weekly skin assessments or timely treatment for a developing pressure injury. Although the care plan called for skin checks each shift and assistance with turning and repositioning, there were no physician orders for weekly skin assessments, and after staff first noted an unstageable pressure injury on the hip, several days passed without documented treatment orders or care. A wound physician later documented a full-thickness Stage 3 pressure ulcer that had been present for more than one day, which progressed and, after surgical debridement, was staged as a Stage 4 ulcer. Interviews with RNs, the DON, and the wound care physician confirmed that routine skin assessments were not consistently completed or documented, and that the wound’s condition indicated it should have been identified earlier.
A resident with multiple chronic conditions had a physician order and POLST indicating DNR/No CPR, but the EMR banner listed the resident as “Full Code,” and the POLST was not timely scanned into the record. After the resident fell, an RN informed EMS that the resident was a full code based on the EMR banner, and EMS initiated full resuscitative efforts when the resident became pulseless. The DON and wound care nurse reported that residents are treated as full code until paperwork is received and that the admitting nurse would not have entered a DNR order without having the POLST, indicating the facility possessed the DNR documentation but failed to update the EMR banner, resulting in resuscitation contrary to the resident’s advance directive.
A resident with a stage 4 sacral pressure ulcer and CT-confirmed osteomyelitis did not receive the ordered oral antibiotic linezolid as prescribed, resulting in multiple missed doses. The wound physician ordered ciprofloxacin and linezolid for an extended course, but only linezolid was entered as a physician order, and the MAR showed that only a fraction of scheduled doses were administered. Facility staff reported that the contracted pharmacy flagged linezolid as a high-cost medication, supplied only a few days’ worth, and that the DON and others were attempting to secure coverage through the VA while continuing ciprofloxacin. The family was told they could not bring in cheaper medications from an outside pharmacy, and the administrator stated that high-cost drugs must go through the contracted pharmacy or VA. The DON later reported that the resident’s POA declined treatment after learning the cost, and that they discussed holding the medication and IV alternatives with the physician, but these discussions were not documented in the record until later, contrary to the facility’s policy requiring medications to be administered as prescribed.
A resident's HPOA was not notified by staff after the resident fell from bed, despite facility policy and documentation indicating the intent to notify. The HPOA only learned of the fall from another family member, and staff later acknowledged the failure to notify immediately after the incident.
A resident with limited mobility and cognitive impairment was manually lifted back into bed by staff after a fall, rather than being transferred with a mechanical lift as required. Staff used a blanket as an improvised sling, and the DON confirmed this was not an approved method for resident transfer.
Staff failed to consistently use wheelchair footrests when transporting residents, resulting in unsafe mobility and an incident where a resident fell from a wheelchair and sustained a head laceration requiring sutures. Multiple staff acknowledged the expectation to use footrests for safety, but this was not consistently practiced, and there was no formal written policy in place.
A resident with severe cognitive impairment missed an evening dose of medication, which was later found by a family member and returned to an LPN. The LPN disposed of the pills but did not document the incident or notify the physician, and the facility lacked a policy for medication errors. The required medication error report and physician notification were not completed.
A resident with severe cognitive impairment did not receive her prescribed evening medications, which were later found in her room by a family member. An LPN disposed of the missed medications without documenting the incident or reporting it, and the MAR incorrectly showed the medications as given. The facility lacked a clear medication error policy, and required documentation was not completed at the time of the error.
A resident with SIADH and other complex medical conditions was not administered prescribed sodium chloride for 12 days due to failure in order entry and verification processes by nursing staff. This omission led to critically low sodium levels, confusion, hallucinations, and a prolonged hospital stay to correct the imbalance.
A resident with severe cognitive impairment and a history of falls was found without a call light and left unsupervised, leading to a fall. The facility failed to adhere to the resident's care plan, which required constant supervision and a functioning call light. Staff were unaware of the missing call light, and the facility lacked a designated fall policy.
Two residents experienced unsafe transfer practices in the facility. One resident fell and sustained head lacerations requiring sutures after a CNA's hand slipped off the gait belt during a transfer without a walker. Another resident was transferred without a gait belt, contrary to facility policy. The facility's policies mandate the use of gait belts for all transfers unless contraindicated.
A resident, identified as a high fall risk, fell and sustained multiple fractures and a skin tear during a transfer due to not wearing non-skid footwear and the CNA not holding the gait belt. The resident was wearing slippery socks and no shoes, and the CNA was only guiding the resident by the waist, leading to the fall.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall and new onset pain, but the facility failed to notify a physician immediately. Despite signs of significant pain observed by CNAs, the resident received only initial Tylenol and no further assessment or pain management was documented. The physician was not contacted until the following day, resulting in a 19-hour delay before the resident was transferred to the hospital, where fractures were confirmed.
A resident with severe cognitive impairment and multiple health issues experienced a fall and fractures due to improper transfer methods at a facility. The CNA used a stand aid without a gait belt, leading to the resident's legs giving out and a fall. Staff interviews revealed inconsistencies in transfer methods and a lack of communication regarding the resident's declining ability to bear weight.
The facility failed to manage pressure ulcers for three residents, resulting in severe complications. A resident developed a necrotic sacral wound leading to sepsis and surgery due to improper identification and treatment. Another resident's heel wounds progressed to necrotic eschar due to lack of regular assessments and missing pressure-reducing devices. A third resident's wound care was inadequately documented and treated, with dressings not changed as scheduled. The facility's staff acknowledged lapses in wound assessments and documentation.
The facility failed to implement timely interventions for three residents experiencing significant weight loss. One resident lost 9.91% of their weight in a month without receiving nutritional supplements, and their care plan was updated 20 days late. Another resident lost 10.40% in a month, with a high-calorie diet implemented 17 days late. A third resident lost 18.55% over three months, with delayed protein supplement increases. Meal intakes were not documented for these residents, and the facility's weight monitoring policy was not effectively followed.
The facility failed to implement COVID-19 outbreak interventions, contact isolation precautions, and enhanced barrier precautions. Visitors and residents were not wearing masks in affected areas, and a resident with potential C-diff was not isolated. Staff did not use required PPE for residents needing enhanced barrier precautions, despite clear signage and policy.
The facility failed to treat residents with dignity, as staff engaged in loud arguments and used dismissive language, disturbing residents and making them feel disrespected. Additionally, staff frequently used personal cell phones in resident care areas, detracting from their focus on residents. The DON acknowledged these issues, noting that arguments should not occur in hallways and staff should use more respectful language.
The facility failed to ensure proper labeling and storage of medications in two medication carts. An open insulin pen and bottles of valproic acid lacked resident identifiers and open dates, violating the facility's Pharmaceutical Procedures Policy. Unidentified medication tablets were also found in a cart drawer.
A resident requiring substantial assistance for personal hygiene had persistently dirty nails and hands, despite repeated requests from the spouse to clean them. The CNA confirmed handwashing practices, but the DON acknowledged the need for better hygiene practices, including cleaning under the nails.
A facility failed to prevent cross-contamination during a dressing change for a resident with a local skin infection. A CNA, assisting an LPN, used the same gloves to adjust the bed and handle the wound area without changing gloves or washing hands, contrary to the facility's aseptic guidelines. The DON confirmed the CNA's actions risked contamination.
A resident with multiple diagnoses, including peripheral vascular disease and mild cognitive impairment, did not receive restorative exercises as recommended. The facility's MDS Coordinator admitted to missing the resident in the setup of restorative programming, and the resident, who was in hospice care, reported not being offered exercises. The facility lacked a dedicated Restorative Nurse or Aide, relying on floor staff to perform exercises, which were not documented as completed.
A resident with multiple medical conditions expressed concerns about food quality and service, noting issues like overcooked food and lack of kitchen staff presence at Food Committee meetings. The facility lacked documentation for recent meetings, and the Dietary Manager had not attended due to staffing shortages.
A facility failed to provide treatment per physician's orders for a resident following a fall with injury. The resident, with multiple diagnoses, was observed without a splint or elevated arms as instructed by the hospital discharge summary. The registered nurse and Director of Nursing confirmed the absence of necessary orders in the resident's chart, acknowledging a mistake in the admission process.
Failure to Protect Resident From Abuse and Delay in Reporting Pillow-Over-Face Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when one severely cognitively impaired resident was found placing a pillow over the face/head area of her severely cognitively impaired roommate. In the early morning hours, two CNAs entered the shared room to perform a bed check and observed one resident standing over the other holding a pillow over her face, or a large pillow already over the resident’s face. The resident in bed, who had dementia and severe cognitive impairment and required supervision with mobility, was initially sleeping and did not appear in distress; when awakened, she became agitated, questioned the CNA’s actions, and grabbed the CNA’s arm before calming after reorientation. The resident who placed or was holding the pillow had Alzheimer’s disease with severe cognitive impairment and a history of wandering at night and being redirected back to bed. The CNAs reported difficulty locating a nurse at the time of the incident and each believed another CNA was reporting the event, resulting in a delay in notifying supervisory staff. The Memory Care Director and DON were not informed until later that afternoon, several hours after the incident occurred, despite the facility’s abuse policy requiring that any employee or agent who becomes aware of alleged abuse or neglect immediately report the matter to the administrator. A nurse who was on the unit around the time of the event stated she was not told of the incident. The facility’s own abuse investigation documented the conflicting CNA accounts about whether the pillow was being held over the resident’s face or already covering it, and confirmed that the incident was not promptly reported as required by policy.
Failure to Timely Report Alleged Physical Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of physical abuse when one severely cognitively impaired resident was found with a pillow being held over her face by her severely cognitively impaired roommate. In the early morning, around 5:30 AM, two CNAs entered the shared room during a bed check and observed one resident standing over the other holding a pillow over her face, or a large pillow already over the resident’s face. One CNA removed the pillow and the other removed the aggressor from the room. The resident in bed, who had dementia and severe cognitive impairment and required supervision with mobility, was initially sleeping, became agitated when awakened, and then calmed after being reassured. The roommate, who had Alzheimer’s disease with severe cognitive impairment and required supervision with mobility, had been wandering earlier and had been redirected back to bed. Despite witnessing this event, the CNAs did not immediately report the incident to a nurse or other appropriate authority. One CNA stated she never told the nurse what she had witnessed, and the other CNA reported that she did not report the incident at the time and only called the Memory Care Director later that afternoon after waking up from sleep. Staff who worked the following morning shift, including a CNA and an RN, reported they were not informed of the incident in report. The DON and Administrator both stated they were notified later in the afternoon, and the DON indicated the incident should have been reported when it occurred. The facility’s abuse policy requires that any employee or agent who becomes aware of alleged abuse or neglect immediately report the matter to the facility administrator, which did not occur in this case.
Failure to Perform Skin Assessments and Timely Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for one resident at risk for skin breakdown. The resident had diagnoses including dementia without behaviors, right hip pain, depression, and a documented Stage 3 pressure ulcer to the right hip. A facility assessment showed the resident had moderate cognitive impairment, required partial to moderate assistance with rolling, and was at risk of developing pressure ulcers. The care plan identified increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness, and need for staff assistance with transfers, and included interventions such as assisting with turning and repositioning and performing skin checks each shift. Despite these identified risks and care plan directives, the facility did not perform or document weekly skin assessments for the resident, and there were no physician orders for weekly skin assessments during the relevant period. On a documented date, staff identified what appeared to be an unstageable pressure injury to the right ischial protuberance, measuring 2 x 2 cm, with a completely dry wound bed and indurated edges. A bordered foam dressing was applied and staff indicated they would contact the primary provider for treatment orders and endorsed this to the next shift. However, there were no treatment orders or documentation of any treatments for the pressure wound for several days following this initial identification. Subsequent wound physician notes documented that the wound was a Stage 3 pressure wound of the right hip, full thickness for more than one day, with light serous exudate, and later described necrotic tissue, slough, and granulation tissue. A surgical excisional debridement was performed to remove necrotic tissue and establish viable margins, after which the wound was staged as a Stage 4 pressure wound of the right hip. Interviews with nursing staff and the DON revealed that skin assessments were reportedly done weekly or on shower days, but that if no skin alterations were reported by aides, nurses did not complete skin assessments, and there were no shower sheets. The wound care physician stated that a full-thickness wound of this type would not have developed within a few days and emphasized that facility staff are responsible for completing skin assessments on all residents to identify even small wound alterations. The DON acknowledged the absence of documented weekly skin assessments for this resident and that the wound being found at a late stage was an issue.
Failure to Honor Resident DNR Due to Inaccurate Code Status in EMR
Penalty
Summary
The facility failed to honor a resident’s advance directive by allowing resuscitation efforts to occur despite documented Do Not Resuscitate (DNR) orders. The resident had diagnoses including COVID-19, rib contusion, chronic kidney disease, depression, and venous insufficiency. The physician’s orders specified DNR, and a POLST form indicated “No CPR: Do not attempt resuscitation.” However, the electronic medical record banner listed the resident as “Full Code,” and the POLST form was not scanned into the electronic record until a later date. The facility’s policy required that advance directives be documented in the medical record and specified on the face sheet, and that all advance directives be uploaded into the medical record system and stored in the clinical record. When EMS arrived in response to the resident’s fall, they found the resident prone on the floor, breathing and moaning in pain. A staff member standing next to the resident informed EMS that the resident was a full code, and EMS initiated full resuscitative measures after the resident became pulseless, including manual chest compressions, BVM ventilation with oxygen, IO access, multiple doses of epinephrine, and use of a mechanical CPR device. CPR was continued until arrival at the hospital, where it was discontinued after hospital staff produced a valid DNR on file. The RN later stated she told EMS the resident was a full code because that was what the chart banner showed, and that she relied on the banner as the source of code status. The DON and wound care nurse stated that everyone is treated as full code until paperwork is received and that the admitting nurse would not have entered a DNR order without seeing the POLST, indicating the facility had the POLST but had not updated the banner to DNR, leading to confusion about the resident’s code status.
Failure to Provide Ordered Antibiotic Therapy Due to Cost and Procurement Issues
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when an ordered antibiotic for osteomyelitis was not provided as prescribed. The resident had multiple diagnoses including Parkinson's disease, a stage 4 sacral pressure ulcer, Alzheimer's disease, and dementia, and a CT scan showed findings consistent with osteomyelitis of the coccygeal segments. A wound physician documented that the CT scan of the stage 4 sacral pressure wound demonstrated osteomyelitis and recommended ciprofloxacin 500 mg twice daily for 42 days and linezolid 600 mg twice daily for 42 days. However, the physician’s orders reflected only linezolid 600 mg twice daily, and the medication administration record showed that, over a nine-day period, the resident received only 4 of 16 scheduled doses of linezolid. The resident’s daughter reported that the facility told her rules and regulations did not allow the family to bring in less expensive medications and that she had to contact the VA to obtain coverage for linezolid. She stated that the medication was started two days after it was prescribed and that this delay would have been longer if she had not intervened regarding VA coverage. Nursing staff later stated that linezolid had been discontinued, but the RN interviewed did not know who discontinued it or why, only that it appeared the facility did not have the medication. The DON and wound care nurse explained that the pharmacy identified linezolid as a high-cost medication, that only a few days’ worth of doses were initially supplied, and that they were attempting to secure coverage through prior authorization and the VA while continuing ciprofloxacin. The administrator stated that high-cost private pay medications are handled by informing families of the cost and that the facility must use its contracted pharmacy or the VA, not outside pharmacies. The wound physician emphasized that linezolid was important for treating the resident’s suspected osteomyelitis and that it was the only recommended oral antibiotic option, noting that IV alternatives would require RN availability. The DON later stated that the resident’s son/POA declined treatment after learning the cost of the medication and that they discussed holding the medication and possible IV alternatives with the wound physician, but no documentation of these conversations existed in the resident’s progress notes until several days after the issues arose. The facility’s medication administration policy required that all medications be administered as prescribed by the physician, which did not occur in this case, resulting in missed doses and interruption of the ordered antibiotic therapy.
Failure to Notify Power of Attorney After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's Healthcare Power of Attorney (HPOA), who is also the resident's daughter, after the resident experienced a fall from her bed. The resident's face sheet identified her daughter as the HPOA. According to the progress note, the resident fell out of bed at 2:00 AM and was assessed by a nurse, who found no injuries. The nurse documented an intention to call the HPOA around 6:00 AM but did not follow through with the notification. The HPOA was not informed of the fall by facility staff and instead learned about the incident from the resident's sister, who had visited and been told about the fall by the resident herself. During interviews, the HPOA expressed frustration at not being notified immediately, stating her expectation to be informed of any changes regardless of the time. The nurse later acknowledged forgetting to call the HPOA and believed another nurse may have notified her later that day. The Director of Nursing confirmed that family should be notified immediately of any changes in condition, including falls, and that notification is important for informed decision-making. The facility's policy also requires notification of both the physician and the POA following a resident fall.
Failure to Use Mechanical Lift for Post-Fall Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a mechanical lift to safely transfer a resident following a fall. The resident, who had a history of osteopenia, femur fracture, gait abnormalities, and moderate cognitive impairment, was found on the floor next to her bed during overnight rounds. The resident's medical records indicated she had range of motion limitations on one side of her body and used a wheelchair for mobility, with no ability to walk. After the fall, the resident was assessed by a nurse and found to have no injuries at that time. Despite facility protocol requiring the use of a mechanical lift for post-fall transfers, three staff members, including a CNA, an RN, and an LPN, manually lifted the resident back into bed. Accounts from the staff confirmed that they either picked up the resident by her upper and lower body or used a blanket as an improvised sling, rather than using the mechanical lift. The Director of Nursing confirmed that bedding is not an approved lifting device and that a mechanical lift should have been used to prevent injury.
Failure to Ensure Use of Wheelchair Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure safe mobility for residents by not requiring the use of footrests on wheelchairs when staff transported residents. This deficiency was observed in four out of six residents reviewed for safety. In one incident, a resident with multiple diagnoses including vascular dementia, encephalopathy, and muscle weakness was being pushed in a wheelchair without footrests. The resident planted her feet on the floor, resulting in her falling forward out of the wheelchair and sustaining a laceration to her forehead that required three sutures. Staff interviews confirmed that the resident did not have foot pedals assigned to her wheelchair, and the CNA involved did not follow the facility's stated rule for resident safety regarding footrests. Additional observations revealed that other residents were also transported in wheelchairs without footrests. One CNA was seen pushing a resident into the dining room without footrests in place and admitted to forgetting to use them, despite acknowledging that footrests should be used for safety. Another LPN pushed a resident whose foot was sliding across the floor due to the absence of footrests and stated that foot pedals are supposed to be used when pushing residents. Staff consistently reported that footrests are stored in blue bags on the back of wheelchairs and should be used during transport, but this practice was not consistently followed. The facility did not have a written policy specifically addressing the use of footrests on wheelchairs, although staff training and in-service education indicated that all residents using wheelchairs must have foot pedals in place when being pushed. The lack of adherence to this expectation, combined with the absence of a formal policy, contributed to unsafe conditions and resulted in at least one resident injury. Interviews with the administrator and DON confirmed that while staff were trained on the importance of using footrests, there was confusion regarding the existence of a formal policy, and the practice was not consistently enforced.
Failure to Notify Physician and Document Medication Error
Penalty
Summary
A medication error occurred involving a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and a cognitive communication deficit, who resided on the memory care unit. The resident's family member discovered a cup containing the resident's evening medications left in the room and returned it to an LPN. The LPN identified the pills as the resident's missed evening medications from the previous night, disposed of them, but did not document the incident or notify anyone, including the physician. The Director of Nursing later confirmed that the expected procedure in such cases would be to complete a medication error report and notify the physician, but this was not done at the time of the incident. The facility did not have a policy for medication errors, and the required documentation and physician notification were not completed following the discovery of the missed medication dose. The failure to notify the physician and document the medication error was confirmed through staff interviews and record review. The resident was observed to be alert but confused, ambulating independently, and participating in activities at the time of the survey.
Failure to Administer and Document Resident Medications as Prepared
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia and cognitive communication deficit, did not receive her prescribed evening medications as intended. The medications, which included alprazolam, aspirin, atorvastatin, carvedilol, clopidogrel, and Seroquel, were found in a cup in the resident's room by her family member, rather than being administered. The nurse on duty disposed of the medications after confirming they were missed doses from the previous evening, but did not document the incident or report it at the time. The Medication Administration Record (MAR) incorrectly indicated that the medications had been given, with no notation of a missed dose or medication error. Further review revealed that the facility lacked a specific policy for medication errors, though their medication administration policy required documentation in the event a medication could not be given. The Director of Nursing confirmed that a medication error report should have been completed in this situation, but it was not done until after the incident was discovered. The failure to administer the medications as prepared, document the missed dose, and report the error constituted a deficiency in pharmaceutical services for the resident.
Failure to Administer Ordered Sodium Chloride Results in Critical Medication Error
Penalty
Summary
A resident with diagnoses including permanent atrial fibrillation, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), chronic kidney disease, and malignant neoplasm of the bladder was admitted to the facility with hospital discharge orders for sodium chloride 1gm PO QID. Upon review, there were no physician orders entered for sodium chloride, nor was there any evidence on the medication administration record that the resident received sodium chloride during the entire stay at the facility. The nurse practitioner’s note indicated that sodium chloride was necessary for the management of SIADH, and the expectation was that the medication was being administered as ordered. Interviews with facility staff revealed that the admission nurse was responsible for entering the orders and that a second nurse was supposed to double-check the orders for accuracy. However, both the initial entry and the double-check failed to identify the omission of the sodium chloride order, resulting in the resident not receiving the prescribed medication. As a result of not receiving sodium chloride, the resident developed a critically low sodium level, became confused, and experienced hallucinations. The resident was subsequently hospitalized for 15 days to correct the sodium imbalance. Hospital records confirmed a sodium level of 115, which was identified as a critical lab value. The facility’s policies required accurate transcription and administration of physician’s orders, but these procedures were not followed in this case.
Failure to Provide Call Light and Supervision
Penalty
Summary
The facility failed to provide a call light to a resident, identified as R2, and did not ensure adequate supervision while the resident was in her wheelchair. R2, who has severe cognitive impairment and requires substantial assistance for transfers, was found without a call light in her room. The resident's care plan indicated that she was at risk for falls and should not be left unattended, yet she was found on the floor after being left alone in her room. The facility's accident/incident report noted that R2 had experienced nine falls in the past six months, highlighting the need for strict adherence to her care plan. During the survey, it was observed that R2's call light was detached and not accessible, and staff were not aware of this issue. A Certified Nursing Assistant mentioned that R2 does not use a call light, implying a lack of understanding of the resident's needs. The Interim Director of Nursing acknowledged the absence of the call light and the failure to follow the care plan, which contributed to the resident's fall. Additionally, the facility was unable to provide a fall policy when requested by the surveyor, indicating a gap in their safety protocols.
Unsafe Transfer Practices Result in Resident Injury
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents, resulting in one resident sustaining injuries. Resident R1's care plan outlined specific steps for safe transfers, including the use of a walker and a gait belt. However, during a transfer on January 3, 2025, a CNA assisted R1 without the use of a walker, and although a gait belt was applied, the CNA's hand slipped off the belt, leading to R1 falling forward and hitting her head on the floor. This incident resulted in R1 sustaining multiple lacerations to her forehead and under her left eye, requiring sutures. The Director of Nursing noted that R1's slippers might have contributed to the fall due to insufficient grip. Additionally, Resident R3, who is at risk for falls due to weakness, was transferred to the toilet by a CNA without the application of a gait belt, contrary to the facility's policy. The CNA admitted to forgetting to use the gait belt during the transfer. The facility's policies clearly state that gait belts should be used for all transfers unless contraindicated, and the failure to adhere to these policies contributed to the unsafe transfer practices observed.
Failure to Ensure Resident Safety During Transfer
Penalty
Summary
The facility failed to ensure a resident was wearing non-skid footwear and was being held by the gait belt during a transfer, resulting in a fall and injuries. The resident, who was identified as a high fall risk, was being assisted from a recliner to a bed by a CNA. During the transfer, the resident was wearing regular socks, which were slippery, and no shoes. The CNA was not holding onto the resident's gait belt, only guiding him by the waist. As a result, the resident slipped and fell, sustaining a rib fracture, two transverse process fractures of the lumbar vertebrae, and a skin tear. The resident's medical history included a fracture of the neck of the right femur, presence of a right artificial hip joint, Parkinson's disease, muscle weakness, unsteadiness on feet, pain, and a history of falls. The incident was reported, and it was noted that the resident felt he slipped because he was not wearing shoes. The facility's staff, including the LPN and the DON, confirmed the resident was not wearing appropriate footwear and the CNA was not holding the gait belt during the transfer, which contributed to the fall.
Failure to Notify Physician and Assess Resident Post-Fall
Penalty
Summary
The facility failed to immediately notify a physician of a fall involving a resident, identified as R1, who experienced new onset pain and required medical attention. R1, who had severe cognitive impairment and multiple medical conditions including congestive heart failure and Alzheimer's disease, was lowered to the floor during a transfer due to bilateral leg weakness. Despite complaining of pain in the left shoulder, the initial assessment by the nurse found the range of motion to be within normal limits, and Tylenol was administered. However, the nurse did not notify the physician immediately, instead placing a notification form in the nurse practitioner's binder for review on the next visit. Throughout the day following the fall, R1 continued to exhibit signs of significant pain, as reported by multiple CNAs who observed him wincing, screaming, and refusing to eat. Despite these observations, there was no evidence of further assessment or pain management beyond the initial administration of Tylenol. The nurse on duty during the day shift did not document any assessment or administer additional pain medication, and the physician was not contacted until the following day when R1's condition had worsened, showing significant bruising and inability to perform range of motion exercises. The facility's policies required immediate notification of a physician following an incident resulting in injury, as well as ongoing assessment and documentation of a resident's condition post-fall. However, these procedures were not followed, resulting in a delay of 19 hours before R1 was transferred to the hospital for evaluation, where fractures were confirmed. The lack of timely assessment and communication with medical providers contributed to inadequate pain management and delayed treatment for R1.
Failure to Safely Transfer Resident Results in Injury
Penalty
Summary
The facility failed to perform a safe transfer for a resident, resulting in a fall and subsequent fractures to the resident's left arm and shoulder. The resident, who had severe cognitive impairment and required substantial staff assistance for transfers, was being transferred by a CNA using a stand aid. The CNA attempted to transfer the resident without a gait belt, and the resident's legs gave out during the process, causing him to fall. The CNA was unable to prevent the fall, and the resident sustained significant injuries. The resident's care plan initially indicated the use of a stand aid for transfers, but after the incident, it was updated to require a full mechanical lift with staff assistance of two. The incident report noted that the resident was lowered to the floor during the transfer due to bilateral leg weakness. Despite initial assessments indicating no significant injury, the resident later complained of increased pain, leading to an emergency room visit where fractures were confirmed. Interviews with staff revealed inconsistencies in the transfer methods used for the resident, with some staff using a gait belt and others not. The CNA involved in the incident admitted to not using a gait belt and was unaware of the requirement until after the fall. The Director of Nursing and other staff members acknowledged that the resident's transfer status should have been reassessed due to his declining health and inability to bear weight, which was not communicated effectively among the staff.
Inadequate Pressure Ulcer Management Leads to Severe Complications
Penalty
Summary
The facility failed to properly identify and manage pressure ulcers for three residents, leading to severe complications. Resident R75 was admitted without skin alterations but later developed a sacral wound that was not correctly identified or treated as a pressure ulcer. The wound progressed to a necrotic state, resulting in sepsis and requiring surgical intervention, including debridement and the placement of a colostomy. The wound care nurse and Director of Nursing acknowledged the lack of proper wound assessments and documentation, which contributed to the deterioration of R75's condition. Resident R63 also suffered from inadequate pressure ulcer management. Despite having a care plan that included the use of pressure-reducing devices, R63 was observed without heel protectors, and his wheelchair lacked a cushion. His heel wounds were not assessed regularly, leading to the development of necrotic eschar. The Wound Care Physician noted that the assessment of R63's wounds was incorrect and that early intervention could have prevented the progression of the wounds. Resident R16 experienced a lapse in wound care documentation and treatment. Her pressure injuries, which developed after a fall and subsequent casting, were not properly documented or treated according to the facility's schedule. The dressings on her wounds were not changed as required, and there was no record of refusal for treatment. The facility's Director of Nursing and Wound Nurse admitted to not maintaining records of R16's wounds, relying instead on external wound clinic assessments, which led to gaps in care.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to implement timely interventions for residents experiencing significant weight loss, affecting three residents in particular. Resident 82 experienced a 9.91% weight loss in one month, with no nutritional supplements provided despite the weight loss being identified. The Registered Dietitian's recommendations were delayed, and the care plan was not updated until 20 days after the weight loss was noted. Additionally, there was no documentation of meal intakes for this resident, and the facility lacked a permanent Registered Dietitian, which contributed to the delay in addressing the weight loss. Resident 70 experienced a 10.40% weight loss in one month. Despite the Nurse Practitioner being notified of the weight loss, no new orders were given initially. The Registered Dietitian recommended a high-calorie diet, but the change was not implemented until 17 days after the weight loss was identified. Similar to Resident 82, there was no documentation of meal intakes for Resident 70, indicating a lack of monitoring of nutritional intake. Resident 83 experienced an 18.55% weight loss over three months and a 12.17% loss in one month. The Nurse Practitioner was notified, but no new orders were given initially. The Registered Dietitian recommended increasing protein supplements and weekly weights, but these interventions were delayed. There was also no documentation of meal intakes for Resident 83. The facility's policy on weight monitoring was not effectively followed, as significant weight losses were not addressed promptly, and the Registered Dietitian's recommendations were not implemented in a timely manner.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement COVID-19 outbreak interventions, contact isolation precautions, and enhanced barrier precaution interventions, potentially affecting all residents. Observations revealed that visitors and residents were not wearing masks in areas where a staff member had tested positive for COVID-19. The Infection Preventionist confirmed that the facility was in outbreak status, and source control should have been implemented on the affected units. However, there was confusion among staff regarding mask-wearing protocols, leading to inconsistent application of source control measures. The facility also failed to implement contact isolation precautions for a resident exhibiting symptoms of Clostridioides difficile (C-diff). Despite the resident's ongoing diarrhea and a physician's order for a stool sample, there was no signage indicating isolation, and the sample had not been sent to the laboratory. The Director of Nursing acknowledged that the resident should have been in contact isolation pending test results to prevent potential spread. Additionally, the facility did not adhere to enhanced barrier precautions for residents with pressure ulcers and other conditions requiring such measures. Staff were observed providing care without the necessary personal protective equipment, despite signage and facility policy indicating the need for gowns and gloves during high-contact activities. This lack of adherence to infection control protocols was noted by the Director of Nursing, who stated that staff should have been aware of the requirements.
Staff Behavior and Cell Phone Use Compromise Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by multiple incidents involving staff behavior. Several residents reported being disturbed by loud arguments between staff members in the early morning hours, which woke them up and made them feel disrespected. The residents described the staff as rude, often responding to their needs with dismissive phrases like 'What do you want?' instead of more respectful language. The Director of Nursing acknowledged the inappropriate behavior, noting that the argument should not have occurred in the hallway and that staff should use more considerate language when addressing residents. Additionally, the facility did not enforce its policy on cell phone usage, leading to further concerns about resident care. A CNA was observed using a personal cellphone in a resident care area, and residents reported that staff frequently used their phones instead of attending to their needs. Meeting minutes from resident council meetings indicated ongoing issues with staff using cell phones during resident care and meal times, which detracted from their focus on residents. The facility's policy prohibits cell phone use in resident care areas to prevent privacy violations and ensure staff attention is directed towards residents.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were clearly labeled and stored properly, as observed in two of the three medication carts reviewed. On one occasion, an open insulin flex pen was found in a medication cart drawer in the dementia unit without any indication of when it was opened or to whom it belonged. Similarly, another medication cart contained an open insulin flex pen with no date or resident identifiers. Additionally, a 500 ml bottle labeled as valproic acid 250 mg was found with over 300 ml of liquid remaining, but the label lacked the full concentration of the medication, legible resident information, and an open date. Another bottle of valproic acid was found wet and stuck to the drawer, also missing an open date and clear resident identifiers. Four unidentified white medication tablets were also found at the bottom of the drawer. The facility's Pharmaceutical Procedures Policy, dated 1/5/23, requires that medication labels clearly indicate the resident's full name, physician's name, prescription number, drug name and strength, administration directions, issue date, expiration date, pharmacist initials, and medication amounts. The policy also mandates that medications with soiled, damaged, incomplete, illegible, or makeshift labels be returned to the issuing pharmacist for relabeling or disposal. Medications without labels should be destroyed according to state and federal regulations. The policy emphasizes proper storage conditions for drug supplies, including sanitation, temperature, light, refrigeration, and moisture, and requires that each resident's medications be kept in their originally received container.
Failure to Maintain Hand Hygiene for Resident
Penalty
Summary
The facility failed to provide adequate hand hygiene for a resident, identified as R64, who required substantial assistance for personal hygiene. On multiple occasions, R64's spouse expressed concerns about the resident's dirty nails and hands, which were observed to have dirt and grime under the nails and a dried red substance on the hands. Despite the spouse's repeated requests to the nursing staff to clean R64's nails, the issue persisted. A Certified Nursing Assistant (CNA) confirmed that R64 did not refuse care and stated that handwashing was performed when hands were soiled and before meals. However, the Director of Nursing acknowledged that staff should be washing residents' hands before meals, when soiled, and after using the bathroom, and also cleaning under the nails for infection control. The Director observed R64's nails and confirmed they were dirty and needed cleaning.
Failure to Prevent Cross-Contamination During Dressing Change
Penalty
Summary
The facility failed to provide a dressing change in a manner that prevents cross-contamination for a resident with multiple diagnoses, including a local infection of the skin and subcutaneous tissue. During a dressing change for the resident's scrotum, a CNA, while assisting an LPN, used the same gloved hands to adjust the bed's height by touching the buttons on the footboard. After adjusting the bed, the CNA returned to the resident and continued to handle the wound area without changing gloves or washing hands, thereby risking contamination. The Director of Nursing confirmed that the CNA should have removed the gloves, washed hands, and donned new gloves before touching the resident again. The facility's policy on wound care emphasizes the need for aseptic techniques and standard precautions to protect wounds from contamination and infection. The actions of the CNA were contrary to these guidelines, as they potentially transmitted infection by contaminating both the resident and the bed controls.
Failure to Provide Restorative Exercises to Resident
Penalty
Summary
The facility failed to provide restorative exercises to a resident, identified as R63, who was reviewed for range of motion. R63 had diagnoses including peripheral vascular disease, pneumonia, pressure-induced deep tissue damage of the left hip, and anxiety disorder. The facility's assessment indicated that R63 had mild cognitive impairment and was supposed to receive restorative nursing programs for active range of motion, bed mobility, and dressing and/or grooming. However, documentation showed that R63 did not receive any restorative services from February 2024 through August 2024, despite a therapy recommendation suggesting restorative programs for transfers and lower body exercises. The Minimum Data Set (MDS) Coordinator, identified as V22, acknowledged that R63 was not on a restorative program and admitted to missing this resident in the setup of restorative programming. V22 mentioned that the facility did not have a dedicated Restorative Nurse or Aide, and the floor staff were responsible for performing the exercises. R63, who was enrolled in hospice care, stated that they had not been offered any exercises and felt hesitant to ask due to the staff's busy schedule. The facility's policy emphasized the importance of providing a program to assist residents in achieving and maintaining their maximum level of function, but this was not implemented for R63.
Failure to Address Resident Food Preferences
Penalty
Summary
The facility failed to consider the food preferences of a resident, identified as R9, who was cognitively intact and had various medical conditions including chronic obstructive pulmonary disease and major depressive disorder. R9 expressed concerns about the food quality and service, noting issues such as not receiving lemon with iced tea, overcooked and undercooked food items, and the inability to request additional items from the kitchen due to staff leaving immediately after meal delivery. R9 also mentioned that kitchen staff had not attended the monthly Food Committee meetings for the past three months, preventing residents from voicing their concerns directly. The facility lacked documentation for the Food Committee meetings for June, July, and August, and the Dietary Manager, V6, confirmed he had not attended these meetings due to being short-staffed. The facility's policy on Menu Preference sheets did not address ensuring resident preferences were considered, and there was no policy or procedure related to the Food Committee meetings. Previous meeting minutes from March to May indicated ongoing concerns about food quality, including cold and overcooked items, and staff leaving before addressing residents' needs.
Failure to Follow Physician's Orders After Resident's Fall
Penalty
Summary
The facility failed to provide treatment per physician's orders for a resident following a fall with injury. The resident, who has diagnoses including traumatic subarachnoid hemorrhage, urinary tract infection, muscle weakness, and osteoarthritis, was observed without a splint or elevated arms as instructed by the hospital discharge summary. The resident expressed discomfort and soreness in her hand, indicating that the prescribed treatment was not being followed. The registered nurse, who was an agency nurse, confirmed that there were no orders in the resident's chart for the splint or arm elevation, and the Director of Nursing acknowledged that the discharge instructions should have been entered into the resident's chart as physician's orders. The deficiency was identified when the therapy department noticed the absence of the splint and brought it to the attention of the registered nurse. The Director of Nursing admitted that it was a mistake by the nurse who admitted the resident back to the facility and that the necessary interventions should have been in place. The facility does not have a specific policy regarding physician's orders but follows standard nursing procedures to enter orders upon a resident's return from the hospital and confirm them with the attending physician.
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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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