Mercer Manor Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Aledo, Illinois.
- Location
- 309 N W 9th Avenue, Aledo, Illinois 61231
- CMS Provider Number
- 146138
- Inspections on file
- 21
- Latest survey
- January 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mercer Manor Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide an ongoing program of activities for residents in the Memory Care Unit due to insufficient activity staff and unrealistic expectations for CNAs to lead activities. Observations revealed residents sitting idle without engagement, and scheduled activities were not conducted. The activity director acknowledged staffing shortages and the unsuitability of certain activities for residents' needs.
The facility failed to document appropriate indications for antipsychotic medication use for several residents, lacking specific behaviors or symptoms in their care plans. Despite facility policy requiring documentation of behaviors and responses to non-pharmacological interventions, residents were prescribed medications like Haloperidol and Risperidone without proper justification. The Director of Nursing acknowledged the issue, noting that some staff believed medication was the solution to behavioral issues, contributing to the problem.
A facility failed to include a resident's oxygen use in their comprehensive care plan, despite a physician's order for oxygen at 2 liters per minute via nasal cannula for dyspnea or chest pain. Observations confirmed the resident was using oxygen, but the care plan lacked information or goals regarding this need. The care plan coordinator confirmed the omission.
A facility failed to follow a care plan for a resident with CHF, neglecting to document daily weights and report significant weight changes to the cardiologist as ordered. The MAR showed missing weight entries and unreported weight gains over several months, despite clear discharge instructions. The DON confirmed the oversight, acknowledging the cardiologist should have been notified.
A facility failed to assess and document a pressure ulcer for a resident, identified as having multiple open areas on the coccyx. The facility's policy requires weekly assessment of skin impairments, but the wound was consistently documented as irritant contact dermatitis without measurements. The DON confirmed reliance on telehealth wound care doctors and acknowledged the wound's location over a pressure point, yet it was not documented as a pressure ulcer.
A facility failed to change a resident's oxygen equipment as ordered, with the nasal cannula and humidifier bottle not being replaced weekly as required. The resident's Physician Order Sheet specified weekly changes for infection control, but records showed the last change was documented mid-month, with no updates for subsequent weeks. Observations confirmed the equipment was not updated, and the DON acknowledged the oversight.
A registered nurse failed to follow infection control protocols during medication administration for a resident with a gastric tube. The nurse placed a medication cup on the resident's bed, causing it to tip over and spill pills onto the sheet. The nurse picked up the pills and administered them, acknowledging later that the bed sheet was not clean.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from a memory care unit due to inadequate alarm systems and supervision. The resident was found outside with significant injuries, including facial and cervical spine fractures, after exiting the facility unnoticed. The facility failed to update the resident's care plan and did not report the elopement to the State Agency, contributing to the severity of the incident.
Facility dietary staff failed to have their hair restrained while handling and preparing food, potentially affecting all 60 residents. Observations revealed multiple instances of non-compliance, including a Dietary Assistant serving food without a hair net, another with loose hair hanging from a cap, and a Dietary Cook with an improperly worn hair net. The Dietary Manager confirmed the requirement for full hair restraint.
The facility failed to provide twice-weekly showers for a resident diagnosed with Dementia and Parkinson's Disease, who required assistance for all ADLs. Despite being scheduled for showers on Wednesdays and Saturdays, the resident only received 20 out of 34 scheduled showers. Staff confirmed the missed showers and noted that the resident enjoyed showers and did not resist them. The DON verified the missing shower records.
Inadequate Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities for residents in the Memory Care Unit, as required by their policy. Observations and interviews revealed that the activity staff were not consistently present on the unit, and the activities listed on the calendar were not being conducted. For instance, on multiple occasions, residents were found sitting idle without any engagement, and the activity staff did not arrive to conduct scheduled activities like 'Parachute Fun.' The lack of activity staff presence was attributed to staffing shortages, with only one activity aide working part-time and another full-time aide not covering the Memory Care Unit on weekends or certain weekdays. The report highlights specific instances where residents were left without meaningful engagement. On one occasion, a nurse and a CNA were unable to facilitate a craft activity due to insufficient staffing and concerns about residents' safety with small craft pieces. Additionally, residents were observed sitting in common areas without any music, television, or accessible activity materials, contrary to their care plans that emphasized the importance of music and other forms of engagement. The activity director acknowledged the inadequacy of the current staffing levels and the unsuitability of certain activities for the residents' needs. The facility's failure to provide adequate activities was further compounded by the lack of resources and support for the nursing staff to lead activities. The activity director admitted that the expectation for CNAs to lead activities was unrealistic given their other responsibilities. The report also noted that there were no activities on weekends and certain weekdays due to the limited availability of activity staff, leaving residents without structured engagement during these times.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure appropriate indications for the use of antipsychotic medications and did not identify or document target behaviors for several residents. The report highlights that six residents were administered antipsychotic medications without proper documentation of specific behaviors or symptoms that necessitated such treatment. The facility's policy on psychotropic medication management requires documentation of specific behaviors and the resident's response to non-pharmacological interventions, which was not adhered to in these cases. For instance, one resident with diagnoses including Frontotemporal Neurocognitive Disorder and Schizophrenia was receiving Haloperidol and Quetiapine, yet their care plan did not include target behaviors justifying the use of these medications. Another resident with Moderate Severity Dementia and Mood Disorder was on Risperidone without having been seen by psychiatric services, and their care plan also lacked documentation of target behaviors. Similar issues were noted with other residents, where antipsychotic medications were prescribed for conditions like dementia and anxiety without clear documentation of behaviors that would warrant such treatment. The Director of Nursing acknowledged the issue, stating that the psychiatric services had only recently started, and some staff believed medication was the solution to behavioral issues, contributing to the problem. The care plans for these residents did not include target behaviors as part of the reason for the psychotropic medications, indicating a systemic issue in the management and documentation of antipsychotic medication use in the facility.
Failure to Include Oxygen Use in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive assessment for the use of oxygen for a resident reviewed for care plans. The facility's policy, revised in June 2024, requires an individualized comprehensive care plan with measurable objectives and timetables to meet each resident's needs. However, the resident's Physician Order Sheet from December 2024 included an order for oxygen at 2 liters per minute via nasal cannula as needed for dyspnea or chest pain, but the current comprehensive care plan did not contain information or goals regarding oxygen usage. Observations on two separate days confirmed the resident was using oxygen, yet the care plan coordinator acknowledged the omission of the resident's oxygen needs in the care plan.
Failure to Monitor and Report Weight Changes in CHF Resident
Penalty
Summary
The facility failed to adhere to the prescribed care plan for a resident with congestive heart failure (CHF), specifically regarding daily weight monitoring and reporting significant weight changes to the cardiologist or CHF clinic. The hospital discharge instructions for the resident required daily weighing at the same time and on the same scale, with any weight gain of 3 pounds in one day or 5 pounds in one week to be reported to the cardiologist. However, the Medication Administration Record (MAR) for the resident showed multiple instances of missing weight documentation across several months, including August, September, October, November, and December. Despite documented weight gains that met the criteria for notification, there was no evidence in the medical records that the cardiologist or CHF clinic was informed of these fluctuations. The Director of Nursing confirmed the missing documentation and acknowledged that the cardiologist should have been notified according to the parameters set on the discharge instructions. This oversight in monitoring and communication represents a failure to provide appropriate treatment and care as ordered, potentially impacting the resident's cardiac health management.
Failure to Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and measure a pressure ulcer for one resident, identified as R23, among two residents reviewed for wounds. The facility's Skin Prevention, Assessment and Treatment policy requires weekly assessment and documentation of all skin impairments, including pressure ulcers, by the Wound Nurse or designee. However, R23's wound care assessments consistently referred to the wound as irritant contact dermatitis and did not include measurements or documentation of multiple open areas on the coccyx, despite the presence of four small slit-like open areas observed during a survey. The Director of Nursing (DON) confirmed that the facility does not measure non-pressure ulcers and relies on telehealth wound care doctors who do not perform hands-on assessments. The DON acknowledged that R23's wound was due to immobility and incontinence and was located directly over the pressure point of the coccyx. Despite this, the wound was not documented as a pressure ulcer, and there was no record of the number of open areas present. This lack of thorough assessment and documentation led to the deficiency identified by the surveyors.
Failure to Change Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that oxygen equipment was changed as ordered for a resident, identified as R33, who was reviewed for respiratory care. According to the facility's Oxygen Administration and Storage policy, nasal cannulas or masks should be changed weekly or when soiled, and the humidifier bottle should be labeled with the date of application and changed weekly if refillable. R33's Physician Order Sheet dated December 19, 2024, specified that the oxygen water bottle should be changed on the night shift every Sunday and as needed, with the bottle being dated and initialed, and the oxygen tubing changed every Sunday and as needed for infection control. However, the Treatment Administration Record for December 2024 showed that the last documented change of R33's humidification bottle was on December 15, 2024, with no documentation for the subsequent Sundays, December 22 and December 29, 2024. Observations on January 7 and January 8, 2025, revealed that R33's nasal cannula tubing and refillable humidifier bottle were still dated December 16, 2024. The Director of Nursing confirmed that both the nasal cannula and the humidifier bottle should have been changed weekly, indicating a failure to adhere to the prescribed schedule for changing the oxygen equipment.
Medication Administration Breach in Infection Control
Penalty
Summary
The facility failed to adhere to its Standard Precautions policy during a medication administration for a resident. A registered nurse was observed preparing medications for a resident with a gastric tube. During the process, the nurse placed the medication cup on the resident's bed, which resulted in the cup tipping over and spilling two pills onto the fitted sheet. The nurse then picked up the pills with a gloved hand and returned them to the cup, subsequently administering all the medications via the resident's gastric tube. The nurse later confirmed that the pills had fallen onto the bed and acknowledged that the bed sheet would not be considered clean, indicating a breach in infection control practices.
Inadequate Alarm System and Supervision Lead to Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that the memory care unit exit doors and bracelet alarms were loud and widespread enough to alert staff when activated. This deficiency resulted in a cognitively impaired resident, who was at high risk for elopement, exiting the facility without staff knowledge. The resident was found outside in the parking lot, soaking wet and with significant injuries, including facial and cervical spine fractures, after having eloped from the facility's locked memory care unit. The incident occurred during a time of heavy rain, and the resident was later transferred to a tertiary hospital for intensive care treatment. The resident involved had a history of severe cognitive impairment and was known to be an exit seeker. Despite this, the care plan had not been updated with new interventions since 2023, and the facility failed to follow its own elopement policies. The alarms on the exit doors were not audible enough to alert staff, especially when they were in resident rooms or further up the hall. Staff interviews revealed that the resident had previously managed to exit the building, indicating a pattern of inadequate supervision and alarm system failures. The facility's policies required that all incidents of elopement be reported to the State Agency and result in a comprehensive care plan review and revision. However, the facility did not report the elopement incident to the State Agency, as they believed the resident was still on the property. This oversight, along with the failure to investigate and address previous elopement attempts, contributed to the severity of the incident and the resulting injuries to the resident.
Removal Plan
- An audit of the memory care unit's alarms was conducted and determined that all exit alarms are functioning and audible, including behind closed doors. All 17 rooms were audited on the unit, including the room furthest from the exit.
- All nursing staff present were in-serviced on: Proper monitoring and supervision of residents at risk for elopement - The definition of elopement - Review of the facility's elopement detection and prevention systems - The need to reassess and review a resident's plan of care after an elopement.
- All residents at high risk for elopement have been reviewed and no instances of exiting the building unattended have been identified.
Dietary Staff Non-Compliance with Hair Restraint Policy
Penalty
Summary
Facility dietary staff failed to have their hair restrained while handling and preparing food, which has the potential to affect all 60 residents currently residing in the facility. The facility policy, dated November 5, 2019, directs that hair nets or approved hats covering all hair must be worn while handling or preparing food. However, observations on April 6, 2024, revealed multiple instances of non-compliance. A Dietary Assistant was seen serving food and pouring drinks without a hair net or approved hat, and another Dietary Assistant was observed washing dishes with loose hair hanging from a cap. Additionally, a Dietary Cook was seen with a hair net that did not fully restrain their hair. The Dietary Manager confirmed that all dietary staff are required to have their hair fully restrained while handling and preparing food. The observations were made between 8:30 A.M. and 8:55 A.M. on April 6, 2024. The Dietary Assistant was seen performing various tasks, including plating food, pouring drinks, retrieving and serving brown sugar, and delivering filled plates to residents, all without proper hair restraint. Another Dietary Assistant was observed in the dish room with loose hair hanging from a cap, and the Dietary Cook had a hair net that did not fully restrain their hair. The Director of Nurses verified that 60 residents currently reside in the facility, indicating the potential widespread impact of this deficiency.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide twice-weekly showers for one of four residents reviewed for showers. The facility's policy mandates assisting residents with bathing to maintain proper hygiene and prevent skin conditions. Resident R3, diagnosed with Dementia and Parkinson's Disease, was admitted to the facility and required staff assistance for all Activities of Daily Living (ADLs). According to the facility's shower list, R3 was scheduled to receive morning showers on Wednesdays and Saturdays. However, a review of R3's Certified Nursing Assistant Shower Sheet revealed that R3 only received 20 out of 34 scheduled showers from December 9, 2023, through April 3, 2024. Interviews with Certified Nursing Assistants confirmed the missed showers and noted that R3 enjoyed showers and did not resist them. The Director of Nurses verified that R3 had not been discharged during the specified timeframe and confirmed the missing shower records.
Latest citations in Illinois
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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