Metropolis Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Metropolis, Illinois.
- Location
- 2299 Metropolis Street, Metropolis, Illinois 62960
- CMS Provider Number
- 145813
- Inspections on file
- 33
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Metropolis Rehab & Hcc during CMS and state inspections, most recent first.
The facility failed to provide enough evening staff to meet residents’ needs and respond to call lights in a timely manner. On one evening, a single LPN was observed passing medications on two halls while repeatedly stopping to answer multiple call lights and residents yelling for help, with only one CNA assigned to each hall and no other staff visible for extended periods. A resident remained in a recliner at the nurses’ station for a prolonged time before being taken back to her room, while other residents called out in the hallway. Alert and oriented residents reported waiting over 30 minutes for toileting and incontinence care and sometimes having to clean themselves when staff were unavailable. CNAs and the DON acknowledged that staffing is often limited to one CNA per hall due to call-ins or no-shows, making it challenging to complete required tasks such as answering call lights, toileting, changing, dining assistance, and showers in a timely manner.
Multiple residents were observed eating their evening meals without any drinks at their tables, with some having consumed a significant portion of their food before beverages were offered. A CNA on duty was unsure why the residents had no drinks and only offered a beverage after being prompted, while the DON and Dietary Manager later confirmed that all residents should receive drinks with meals and that CNAs are responsible for preparing and delivering them. Facility policy requires staff to monitor food and fluid intake and address inadequate fluid consumption, but this was not followed for these residents during the observed meal.
A resident with advanced dementia, multiple chronic conditions, and severe cognitive impairment had a care plan addressing agitation and fall risk, including use of a call light and keeping the resident in a wheeled recliner near the nurses’ station, but the plan lacked any focus or interventions specific to bedtime behaviors or refusals to go to bed. Staff observations showed the resident could not appropriately use a call light and was moved between her room and the nurses’ station when she resisted going to bed, while the care plan coordinator and DON acknowledged uncertainty about call light use and described strategies for managing the resident’s bedtime agitation that were not documented in the care plan. The resident’s family member reported not being contacted during an episode of refusal and expressed concern about prolonged sitting due to a pressure sore, confirming the resident was not receiving medication for agitation, highlighting that known behavioral patterns and agreed-upon approaches were not incorporated into the written care plan.
A resident with severe cognitive impairment and a history of repeated falls did not consistently receive prescribed fall prevention interventions, such as keeping the bed in a low position, using a fall mat, and having a nonskid mat in the wheelchair. Staff interviews revealed inconsistent knowledge of the resident's care plan, and observations showed that interventions were not reliably in place. The facility lacked a formal fall policy, and new interventions were not always added after each fall.
Multiple residents experienced a lack of dignity and respect, including being removed from activities for an intimidating meeting about food complaints, being put to bed without toileting assistance resulting in incontinence, and enduring long call light response times due to staffing shortages. Additionally, staff stored personal belongings in a resident's room without consent, despite available staff lockers. These actions and inactions led to residents feeling vulnerable, belittled, and humiliated.
Two residents experienced staff abuse, including an incident where an LPN spat in a resident's face following a verbal and physical altercation, and another case where a resident reported being verbally abused and demeaned by the same LPN. Multiple staff members witnessed or were informed of these events, but there was confusion and lack of proper documentation and follow-up regarding the allegations, resulting in insufficient protection and support for the affected residents.
The facility failed to accurately implement and document physician orders for medication and wound care for three residents. One resident with CHF and COPD did not receive updated medication orders or consistent breathing treatments after hospitalization, and staff failed to communicate changes or assess her condition properly. Another resident with lymphedema and wounds did not receive prescribed compression wraps or wound care due to supply shortages and lack of staff follow-through, and refusals of care were not reported to medical providers. These failures led to significant discomfort, anxiety, and hospitalization for the affected residents.
Several residents with complex medical conditions and significant weight loss did not consistently receive their prescribed diets, nutritional supplements, or appropriate portion sizes as ordered. Observations and interviews revealed that residents missed fortified foods, double portions, and supplements, and sometimes received food textures they could not safely consume. Staff and family confirmed these omissions, and some residents were left without needed eating assistance.
Three residents experienced periods without their prescribed pain medications due to issues with pharmacy supply, physician prescription practices, and regulatory requirements. Pain assessments documented untreated pain, and staff interviews confirmed that alternative medications were ineffective and that required documentation was incomplete.
Multiple residents did not receive their prescribed pain medications or other critical medications as ordered due to issues with prescription processing, pharmacy supply, and lack of authorized prescribers, resulting in untreated pain and delayed medication administration. Staff reported frequent late administration of medications, especially when agency nurses were present, and medications were often left unattended in resident rooms or common areas, violating facility and pharmacy policies for secure storage and administration.
Insufficient staffing led to multiple residents experiencing delays in toileting assistance, hygiene care, and medication administration. Residents with significant care needs were left waiting for extended periods, sometimes resulting in incontinence episodes and late delivery of essential medications. Staff and family members reported that the number of CNAs on duty was often inadequate, particularly during evening and night shifts, and agency staff sometimes left their posts, further impacting care.
The facility did not have any certified dietary staff or a Dietary Manager present in the kitchen, despite policy requiring at least one certified individual during food service hours. This deficiency was confirmed through staff interviews and record review, affecting all 74 residents.
The facility failed to provide adequate and competent dietary staff, resulting in repeated delays in meal service, cold and incomplete meals, and missed dietary accommodations. Residents, family members, and staff reported ongoing issues with meal timeliness and quality, especially after the dietary staff left and non-dietary staff had to prepare and deliver meals without proper resources or training.
The facility did not consistently provide meals and snacks at scheduled times or in accordance with resident preferences and care plans. Several residents, including those with diabetes, reported not receiving bedtime snacks, and staff confirmed that snacks were often unavailable due to the kitchen being locked or not leaving out snack carts. Meals were also frequently served late, with delays attributed to equipment and staffing issues, and there was no formal policy ensuring snack availability for residents who required them.
The facility did not ensure proper operation and monitoring of the dishwashing machine's sanitizer levels, as staff were unfamiliar with testing procedures and documentation was inconsistent or missing. This resulted in dishware not being properly sanitized, potentially affecting all residents.
Surveyors found that the facility did not keep residents warm after showers and failed to provide nail care upon request for several residents. Multiple residents and their families reported that shower rooms were cold, and residents were often returned to their rooms wet or inadequately dressed, causing discomfort. Staff confirmed that residents frequently complained about the cold environment, and one resident repeatedly requested nail care that was not provided. These actions and inactions show a lack of support for resident self-determination and personal care preferences.
Several residents with significant cognitive and physical impairments did not receive timely incontinence care or regular assistance with bathing and showering as required by their care plans. Due to insufficient CNA staffing, residents were left in soiled clothing and bedding, and scheduled showers or bed baths were frequently missed or undocumented. Staff and family interviews confirmed that care was delayed or omitted, and facility leadership could not account for the gaps in care or documentation.
Multiple residents did not receive menu items, condiments, or supplements as ordered, with staff and residents reporting frequent omissions and inconsistencies between dietary tickets and actual food served. Issues included missing butter, jelly, tortillas, desserts, and supplements, as well as a day when only peanut butter and jelly sandwiches and oatmeal were served due to a staff walkout and lack of kitchen resources. Staff interviews confirmed ongoing problems with missing items and late meal service.
Multiple residents, all alert and oriented, reported receiving cold, burnt, or unappetizing food, including cold coffee, hard toast, and burnt sausage. Surveyors confirmed these complaints by measuring food temperatures below the facility's preferred minimum and observing poor food quality. Staff and family members corroborated ongoing issues, citing insufficient kitchen staffing and supplies, especially on evenings and weekends.
Several residents with complex medical needs did not receive food items according to their documented preferences and dietary restrictions, with missing substitutions, delayed service, and incorrect items provided. Staff and resident interviews revealed that dietary staff shortages, supply issues, and poor kitchen conditions led to non-dietary staff preparing limited meal options, resulting in missed supplements and incomplete trays. The facility's own policies for honoring resident preferences and care plans were not followed during this period.
Several residents who were dependent and incontinent did not receive the correct size or type of incontinence supplies due to repeated shortages. Staff reported using smaller or larger briefs, pull-ups instead of briefs, and makeshift alternatives like pillowcases and blankets when standard supplies were unavailable. These shortages affected residents with significant cognitive and physical impairments, leading to discomfort, leaks, and soiled bedding. Staff consistently reported the issue to administration, but the problem persisted over several weeks to months.
A resident with multiple medical and psychiatric diagnoses reported to CNAs that an LPN was verbally abusive, including yelling and making derogatory remarks. The initial CNA did not report the allegation to the Administrator, and although another CNA claimed to have reported it, both the Administrator and DON were unaware of the abuse allegations until informed by a surveyor. The facility's policy requiring immediate reporting of abuse was not followed, and the incident was not investigated until after surveyor intervention.
A resident with multiple medical and psychiatric diagnoses reported verbal abuse by an LPN, including being called 'crazy' and other upsetting remarks. Multiple CNAs and another resident confirmed the complaints, but the administrator and DON stated they were unaware of specific allegations. The facility did not document a care plan focus on abuse, failed to thoroughly investigate the reports, and did not complete required grievance follow-up, resulting in a deficiency.
Several residents with complex medical needs experienced repeated late administration of medications, including insulin and other critical drugs. Staff interviews revealed that high workload, interruptions for resident care, and unfamiliarity with residents contributed to these delays. Facility policy required timely medication administration, but this was not consistently followed.
A resident with a stage 4 pressure ulcer and severe malnutrition did not receive physician-ordered dietary supplements for wound healing. Despite clear orders and care plan interventions, the resident missed prescribed fortified foods, and staff interviews revealed that dietary staff often failed to read supplement instructions on meal tickets or provide requested items, citing time constraints and unavailability.
A resident with a history of falls and requiring assistance for toileting and transfers did not have access to a working call system in the bathroom for approximately two weeks. Staff were aware of the issue but delayed notifying administration and higher-level maintenance, and there was no policy in place for call light systems. The facility's outdated call system further contributed to the deficiency, and the resident's care plan specifically required a functional call light within reach.
Floors in hallways and the dining room were observed to have dried spills, sticky substances, and debris over several days, with staff and a family member confirming that cleanliness had declined due to housekeeping staff shortages and a broken floor cleaning machine. Housekeeping routines were reduced, and common areas were not cleaned daily as required, resulting in unsanitary conditions throughout the facility.
Two residents with cognitive and physical impairments were subjected to sexual and physical abuse by another resident with behavioral issues. In one incident, a female resident was groped in the dining room, and in another, a resident was struck on the head. Both incidents were witnessed by staff and the administrator, and were substantiated through investigation and interviews. The facility's abuse policy prohibits such actions, but these events occurred despite the policy.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, and sexual abuse, physical punishment, and neglect by any person.
A resident with multiple chronic conditions had a signed POLST form indicating a desire for full CPR, but the EHR and order summary incorrectly documented the resident as DNR. The administrator confirmed the inconsistency, which was contrary to facility policy requiring accurate code status documentation.
A resident with severe cognitive impairment and feeding difficulties did not receive the ordered ice cream supplement with meals for two days due to a supply shortage. Staff were unclear about appropriate substitutes, and the dietary director confirmed that fortified pudding should have been provided but was not. The resident's family also observed the missing supplement during meals.
A CNA failed to follow infection control protocols during urinary catheter care for a resident with severe cognitive impairment and multiple medical conditions. The CNA did not perform hand hygiene or change gloves at required times, handled multiple surfaces with contaminated gloves, and returned supplies from the resident's room to the hallway supply cart without proper precautions. The facility's policy required standard precautions and hand hygiene, but these were not followed during the observed care.
The facility failed to prevent falls and elopement for residents with complex medical histories and cognitive impairments. One resident fell from a chair, sustaining severe injuries, while another fell from bed during care, resulting in lacerations. Additionally, a resident with a history of elopement left the facility unnoticed. These incidents highlight inadequate supervision and ineffective implementation of care plans.
The facility failed to maintain a clean and homelike environment for three residents, as reported by residents, family, and staff. A resident reported overflowing trash and unclean surfaces, corroborated by family and staff observations. Another resident noted dust and mold-like substances in her room, requiring her to request cleaning. Staff confirmed issues with housekeeping, including overflowing trash and dirty floors, despite the facility's cleaning procedures.
A resident with cerebral palsy and diabetes type 2 did not receive the required twice-weekly showers, as documented in their care plan. Despite needing assistance, the resident only received one shower per week on several occasions. Interviews with family and CNAs highlighted inconsistencies in the shower schedule, and the facility lacked policies on bathing and ADL care, contributing to the deficiency.
A resident with Alzheimer's and mobility issues experienced multiple falls due to self-transfers. Despite a facility policy requiring updates to care plans after falls, no new interventions were added for several incidents. The RN confirmed the care plan was not updated as required.
A resident with a Foley catheter did not receive catheter care according to facility standards. The CNA failed to separate the labia or cleanse the urinary meatus during the procedure, contrary to the care plan and facility guidelines. The resident's care plan emphasized catheter care every shift and monitoring for UTI symptoms. The CNA acknowledged the oversight, attributing it to nervousness.
A resident with a history of cerebral infarction and gastrostomy status was not administered tube feeding according to physician's orders. The prescribed rate was 40 ml per hour, but observations showed the feeding pump infusing at 30 ml per hour. Staff were unable to recall the correct order, and the facility's protocol for verifying caloric content was not followed.
Two residents' insulin vials were found open without opening dates, violating medication storage protocols. An LPN confirmed the issue, necessitating disposal and replacement of the vials. The facility's policy mandates proper labeling and disposal of insulin after 28 days.
A resident requiring peritoneal dialysis was admitted to the facility without necessary supplies, and the staff were not adequately trained to assist. The resident missed dialysis treatments, leading to confusion and lethargy, and was eventually hospitalized and switched to hemodialysis.
Insufficient Evening Staffing Led to Delayed Call-Light Response and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on the evening shift to meet residents’ needs and to ensure timely response to call lights. On the night of 02/27/26, there were 62 residents in the facility, with one CNA assigned to the 100 hall and one CNA to the 200 hall, and one LPN (V5) passing medications on both halls. Observations between approximately 9:00 PM and 10:07 PM showed repeated instances of call lights activating and residents yelling for assistance while V5 attempted to complete a medication pass. V5 repeatedly had to stop preparing and administering medications to respond to call lights and residents calling out, as no other staff were visible on the halls during much of this time. One resident (R1) was observed asleep in a wheeled recliner at the nurses’ station at 9:04 PM and was not taken back to her room until approximately 9:50 PM. Additional observations documented multiple residents yelling for a nurse or CNA and several call lights going unanswered for periods while V5 continued to juggle medication administration and responding to calls. Around 9:57 PM and again at 9:59 PM and 10:07 PM, two call lights were activated at a time and residents, including R5, were heard yelling in the hallway for help and to talk to someone. R1 was taken to her room by CNA V6 around 9:50 PM and then brought back to the nurses’ station shortly thereafter, with her clothes changed and mumbling to herself. Staff interviews confirmed that on 02/27/26 there was one CNA on each hall, and CNAs had to go back and forth between halls to assist each other, including for residents requiring two-person assistance. Resident and staff interviews, along with staffing records, further supported that staffing levels were insufficient at times to meet residents’ needs in a timely manner. One resident (R6), who was alert and oriented, reported having to wait over 30 minutes at times for assistance with toileting and changing, and stated that staff sometimes did not have time to provide a bed bath, leading him to use wipes to clean himself. Another resident (R8), also alert and oriented, reported having to wait quite a while in the afternoon and evening for help. A grievance form for R6 dated 02/17/26 documented a concern about call lights not being answered timely. CNAs V6 and V7 stated that having only one CNA on each hall can make it challenging to answer all call lights and meet care needs promptly, especially when residents such as R1 and R5 or those requiring two-person assists need more attention. The DON (V2) and Regional Nurse (V17) acknowledged that staffing is based on census, that there are times with only one CNA per hall due to call-ins or no-shows, and that this situation can be very challenging for timely completion of required duties such as answering call lights, toileting, changing, dining assistance, and showers.
Failure to Provide Drinks With Meals to Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide drinks with meals consistent with resident needs and preferences and sufficient to maintain hydration. During an evening meal observation on 03/01/26 at 5:28 PM, four residents (R1, R2, R3, and R4) were seated in the dining room with their meals in front of them but had no drinks at their tables. At that time, R2 and R3 had already eaten approximately one third of their food, and R4 had eaten approximately three quarters of his food, all without drinks present. By 5:44 PM, all four residents were still eating and still did not have drinks in front of them. At 5:45 PM, a CNA (V3) stated she did not know why the four residents did not have drinks and suggested they may have come late, and only then asked one resident (R2) if she wanted something to drink, to which R2 responded affirmatively. Later, the DON (V2) stated that all residents should receive a drink with their meals regardless of arrival time or table changes. The Dietary Manager (V4) confirmed that all residents should receive drinks with their meals, and that CNAs are responsible for preparing and delivering drinks, while the kitchen prepares beverage pitchers. The facility’s undated “24 hour Dining” policy states that staff will monitor residents’ food and fluid intake for adequate consumption and that any staff member observing inadequate fluid intake at meals will refer the resident to the DON and Dining Services Manager for follow-up, but this monitoring and provision of fluids did not occur for the four observed residents during the meal in question.
Failure to Update Care Plan for Cognitively Impaired Resident’s Bedtime Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update and implement an adequate care plan addressing a cognitively impaired resident’s behaviors related to going to bed and remaining in bed. The resident was admitted with Alzheimer’s disease with late onset, dementia, COPD, acute and chronic respiratory failure with hypoxia, pleural effusion, abnormal posture, and low BMI, and was documented on the MDS as severely impaired in decision-making. The care plan identified impaired cognitive function/dementia and behavior problems with agitation, including physical and verbal aggression and rejection of care, with interventions such as offering to return later, calling family, and redirecting the resident. The resident was also care planned as at risk for falls with interventions including ensuring the call light was within reach, use of a nontraditional call light in a recliner, and a directive that when in a wheeled recliner the resident should be out of her room. However, the care plan did not include any focus area or interventions specifically addressing the resident’s behaviors around going to bed, methods to get her to go or stay in bed, or what to do if she refused. Surveyor observations and staff interviews showed that the resident’s actual needs and staff practices were not reflected in the written care plan. On one evening, the resident was observed asleep in a wheeled recliner at the nurses’ station, then taken to her room by a CNA and shortly thereafter brought back to the nurses’ station after refusing to go to bed. Multiple CNAs stated they did not think the resident could use a call light appropriately, and the care plan coordinator acknowledged not knowing if the resident could use a call light, while also stating that if the resident was in her recliner she was not to be left unattended and should be brought to the nurses’ station. The DON reported that the team had discussed strategies such as putting the resident to bed when she appeared tired, calling her daughter if she became agitated, and returning her to the nurses’ station if she remained agitated, but also stated this information should be on the care plan and that the resident could not cognitively use a call light or be left unattended in her room in the recliner. The resident’s family member reported not being called that night and expressed a desire for staff to make a real attempt to get the resident to lie down due to a pressure sore and prolonged sitting, while confirming the resident was not on medications for agitation. These facts demonstrate that the care plan was not updated to reflect known behavioral patterns, limitations in call light use, and agreed-upon approaches to bedtime care.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to provide and implement adequate preventative measures and interventions to prevent falls for a resident with a history of repeated falls and multiple complex medical diagnoses, including Alzheimer's disease, dementia, cirrhosis, heart failure, and reduced mobility. The resident was assessed as having severely compromised cognition and required partial to moderate assistance with transfers and ambulation. Despite being identified as a high fall risk, the care plan interventions were inconsistently implemented, and several falls occurred without new or revised interventions being added to the care plan after each incident. Documentation revealed that the resident experienced multiple falls over a period of time, some of which resulted in injuries such as abrasions and skin tears. Several falls were unwitnessed, and in some cases, the resident was unable to recall or communicate the circumstances of the fall. Observations by surveyors found that prescribed interventions, such as keeping the bed in a low position, using a fall mat, applying bright colored tape to the wheelchair, and providing a nonskid mat in the wheelchair, were not consistently in place. Additionally, the resident's call light was not always within reach, and the resident did not use it even when prompted, despite this being an intervention listed in the care plan. Interviews with staff indicated a lack of awareness and inconsistent knowledge of the resident's fall interventions. Some staff were unaware of specific interventions, and others noted that the resident rarely used the call light. The Director of Nursing confirmed that after each fall, a root cause analysis and new intervention should be implemented, but the care plan and records showed that this was not consistently done. Furthermore, the facility did not have a formal fall policy in place, contributing to the lack of consistent preventative measures and supervision for the resident.
Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to honor residents' rights to dignity, respect, and self-determination in several ways, as evidenced by multiple incidents involving six residents. One cognitively intact resident was removed from a group activity and brought into a meeting with four department heads without prior notice or the opportunity to have a family member present. The meeting was prompted by the resident's voiced concerns about food quality and a family member's social media post about the food. The resident reported feeling intimidated and uncomfortable during the meeting, and staff acknowledged that the approach could have been perceived as intimidating. Documentation also showed that the resident did not initiate or sign a grievance form about the food, despite the form indicating otherwise. Another resident with severe cognitive impairment and dependent on staff for toileting was put to bed without being offered the opportunity to use the toilet, resulting in incontinence and soiled clothing and bedding. The CNA responsible stated that there was insufficient staff available to assist with toileting at the time, and the resident's private caregiver found the resident wet the following morning. Staff interviews confirmed that staffing shortages often led to delays in providing care, and the Director of Nursing acknowledged that this was unacceptable and that licensed nurses were expected to assist when needed. Additional residents reported long wait times for call lights to be answered, sometimes resulting in incontinence episodes. Staff and CNAs confirmed that frequent staffing shortages made it difficult to meet residents' needs in a timely manner. One resident also reported that staff stored their personal belongings in his room without his consent, which he found distressing. Staff admitted to using residents' closets for personal items despite the availability of staff lockers and break rooms, and facility leadership confirmed that this practice was inappropriate. Facility policies reviewed emphasized the importance of treating residents with dignity, respect, and privacy, but these standards were not consistently upheld.
Failure to Protect Residents from Staff Abuse and Inadequate Response to Allegations
Penalty
Summary
The facility failed to protect residents from staff abuse, as evidenced by two separate incidents involving two residents. In the first incident, a resident with severe cognitive impairment, legal blindness, and multiple medical conditions was involved in an altercation with an LPN. The resident, who is known to startle easily and exhibit physical aggression due to her blindness, was at the nurse's station when she began touching the LPN's personal items. The LPN responded by grabbing the resident's hands, leading to a physical exchange where the resident bent the LPN's thumb. The situation escalated verbally, and after the resident spat on the LPN, the LPN retaliated by spitting in the resident's face. Multiple staff members witnessed the event, and the resident was observed wiping her face and expressing distress immediately after the incident. In the second incident, another resident with a history of respiratory and cardiac issues, as well as dementia and anxiety, reported being verbally abused by the same LPN. The resident, who was alert and oriented at the time of the interview, described being called derogatory names and being told her symptoms were imaginary. She documented these statements and reported feeling scared and upset. Several CNAs corroborated that the resident had reported being verbally mistreated and was visibly distressed, with one CNA stating the resident was crying. However, there was confusion and lack of clarity among staff and administration regarding the reporting and investigation of these allegations, with some staff stating they reported the abuse to supervisors, while others, including the DON and Administrator, denied receiving such reports or stated they were unable to investigate further due to lack of specific information. Documentation related to the grievances and follow-up was incomplete. A grievance form was filed by the resident regarding staff conduct, but it lacked specific details, and there was no evidence of consistent follow-up as indicated in the action plan. Progress notes and interviews revealed that the resident continued to express concerns about staff behavior, but the facility's documentation and response to these concerns were insufficient, with missing records of required follow-up meetings and unclear communication among staff regarding the allegations.
Failure to Implement Physician Orders and Provide Wound Care
Penalty
Summary
The facility failed to ensure that physician orders were accurate and implemented for residents following hospitalization and changes in condition, as well as failed to assess and treat lymphedema and wounds per physician orders for three residents. For one resident with a history of acute respiratory failure, COPD, heart failure, and other comorbidities, the facility did not update or implement new orders for furosemide (Lasix) and albuterol as prescribed upon discharge from the hospital. The resident's hospital records indicated a new diagnosis of congestive heart failure and a change in furosemide from as-needed to daily dosing, but the facility continued to administer the medication only as needed. Additionally, the resident's albuterol nebulizer dosage did not match the hospital's discharge instructions, and there was no documentation of a required follow-up physician visit. The resident repeatedly reported difficulty breathing and requested breathing treatments, which were not consistently provided according to orders, and staff failed to assess or respond appropriately to her complaints. Documentation was inconsistent and did not reflect the resident's actual condition, and the nurse practitioner was not notified of the new diagnosis or medication changes due to lack of communication and updates in the electronic health record. Another resident with lymphedema, reduced mobility, and CHF had physician orders for daily compression wraps, wound care, and use of a lymphedema pump. The facility failed to consistently perform and document wound and skin assessments, including measurements and descriptions of wounds, and did not monitor weights to track lymphedema. The resident reported that dressing changes and compression wraps were frequently not performed, sometimes due to lack of supplies such as ace wraps, and staff confirmed that wound care supplies were often unavailable. When the resident refused treatments because they were not performed as she preferred, staff did not notify the physician or nurse practitioner of these refusals, nor did they document or address the resident's requests for alternative treatments. The lack of proper wound care and monitoring led to the resident developing redness, swelling, and altered mental status, resulting in hospitalization for cellulitis and septic shock. Throughout the report, there were multiple instances where staff failed to follow the facility's own medication administration policy, which requires accurate documentation and implementation of physician orders, as well as prompt reporting of changes in condition. There was also a lack of a significant change in condition policy, and communication breakdowns between nursing staff, administration, and medical providers contributed to the deficiencies. The failures resulted in significant discomfort, anxiety, and adverse health outcomes for the residents involved.
Failure to Provide Prescribed Diets, Supplements, and Portion Sizes
Penalty
Summary
The facility failed to provide prescribed diets, nutritional supplements, and appropriate portion sizes according to approved menus for seven residents reviewed for weight loss. Multiple observations and record reviews revealed that residents did not consistently receive the dietary supplements, fortified foods, or double portions as ordered by their physicians and dietitians. For example, several residents did not receive fortified pudding, ice cream, or other supplements at meals, despite these being documented on their dietary tickets and care plans. In some cases, residents received food items that were not appropriate for their dietary needs, such as hard taco shells and churros for a resident without teeth, making it difficult or impossible for them to consume the food provided. Residents affected by these deficiencies had significant medical histories, including diagnoses such as Alzheimer's disease, dementia, Huntington's disease, severe protein calorie malnutrition, dysphagia, and chronic obstructive pulmonary disease. Many of these residents were severely underweight or had experienced notable weight loss, with body mass indexes (BMIs) well below healthy thresholds. Despite care plans and dietary orders specifying the need for additional nutrition, such as fortified foods, double portions, and specific supplements, these interventions were not reliably implemented. Family members and staff interviews confirmed that residents sometimes did not receive the prescribed supplements, and in some cases, staff were either unaware of the orders or reported that the supplements were unavailable. Direct observations during meal times further documented that residents were left without necessary assistance to eat, did not receive the correct food textures, and were not provided with the full portions or supplements as ordered. For example, residents requiring supervision or assistance with eating were sometimes left unattended, and those with orders for pureed or mechanical soft diets received foods that were not suitable for their swallowing abilities. These failures contributed to ongoing harm for residents who were already at risk due to their medical conditions and nutritional status.
Failure to Provide Timely Pain Medication for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for three residents who required such services, resulting in periods where prescribed pain medications were not available or administered as ordered. One resident with severe cognitive impairment and a diagnosis of polyneuropathy had a physician order for hydrocodone-acetaminophen to be given as needed for pain. Documentation showed that this medication was not administered for several days, despite pain assessments indicating moderate pain levels. Staff interviews confirmed that the resident was out of pain medication for over a week, during which time alternative medications like acetaminophen were offered but did not relieve the pain. The resident was observed to cry in pain, and staff were unsure why the medication was unavailable. Another resident with multiple sclerosis and moderate cognitive impairment had a physician order for gabapentin to be administered at bedtime. Medication administration records indicated that the resident did not receive gabapentin for about a week, with staff noting that the resident cried at night due to untreated pain. The lack of medication was attributed to issues with obtaining prescriptions from the physician, and staff were unclear about the reasons for the delay. Pain assessments during this period showed low but present pain levels, and staff interviews confirmed the resident's discomfort during the time the medication was unavailable. A third resident with polyneuropathy and intact cognition had a physician order for Lyrica to be administered twice daily. Medication records showed multiple instances where the medication was not available and not administered, with staff documenting this using a specific chart code but failing to provide corresponding progress notes as required by facility policy. Pain assessments indicated that the resident experienced pain on several days when the medication was not given. Staff interviews revealed ongoing issues with medication availability, particularly for controlled substances, due to challenges with pharmacy supply, physician prescription practices, and regulatory requirements for controlled substances.
Failure to Ensure Medication Availability, Timely Administration, and Secure Storage
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered, and that medications were stored securely for multiple residents. Several residents did not receive their prescribed pain medications, such as hydrocodone-acetaminophen, gabapentin, and Lyrica, for extended periods due to issues with prescription processing, pharmacy supply, and lack of authorized prescribers for controlled substances. Documentation showed that residents experienced untreated pain, with pain assessments indicating moderate to severe pain levels during periods when medications were not available or administered. Staff interviews confirmed that residents were left without their pain medications for up to a week, and alternative medications like acetaminophen were ineffective in relieving their pain. In addition to pain medications, other routine and critical medications, including insulin and diuretics, were administered late on multiple occasions. Medication administration records and audit reports documented numerous instances where medications were given hours after the scheduled time. Staff attributed these delays to high workloads, interruptions during medication passes, agency staff unfamiliarity, and technical issues with electronic systems. Residents and staff reported that late administration was a recurring issue, particularly when agency nurses were on duty, and that this affected the timely management of conditions such as diabetes and heart failure. The facility also failed to maintain secure storage and administration of medications. Observations and staff interviews revealed that medications were left unattended on medication carts, in resident rooms, and in common areas such as the dining room. Medications were sometimes left for residents to self-administer without proper orders or assessments for self-administration capability. Facility policies and pharmacy procedures required medications to be stored securely and not left unattended, but these protocols were not consistently followed, as confirmed by multiple staff and resident accounts.
Failure to Provide Sufficient Nursing Staff Results in Delayed Care and Late Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple incidents involving delayed care, unmet toileting needs, and late medication administration. Several residents with significant cognitive and physical impairments, including those with dementia, incontinence, and mobility deficits, were not assisted promptly with toileting or hygiene, resulting in episodes of incontinence and prolonged exposure to urine and feces. Staff interviews confirmed that there were often not enough CNAs on duty, particularly during evening and night shifts, leading to delays in responding to call lights and providing necessary assistance. Family members and residents reported instances where residents had to wait extended periods for care, sometimes sitting in soiled clothing or bedding. Medication administration was also negatively impacted by insufficient staffing. Multiple residents received their medications, including critical diabetes and heart medications, late on several occasions. Nursing staff, including RNs and LPNs, reported that high workloads, the need to assist with direct care, and interruptions during medication passes contributed to these delays. Agency staff unfamiliar with residents and facility routines further exacerbated the problem, with some agency CNAs reportedly leaving their posts for extended periods during shifts. Facility records and staff schedules revealed that the number of CNAs on duty frequently fell below the facility's stated minimums, especially on night shifts, with as few as two or three CNAs responsible for up to 74 residents. The Director of Nursing acknowledged discrepancies in staffing records and confirmed that licensed nurses were expected to assist with direct care when CNA staffing was insufficient. However, this expectation did not consistently result in timely care for residents, as documented by both staff and resident accounts.
Lack of Certified Dietary Staff in Food Service Department
Penalty
Summary
The facility failed to employ certified dietary staff in the kitchen, as required by their own policy and regulatory standards. On the date of the survey, interviews with the cook and the administrator confirmed that there was no Dietary Manager currently employed, and none of the kitchen staff held a food manager certification. The previous Dietary Manager had left the facility approximately two weeks prior, and no current staff had obtained the necessary certification in the interim. The administrator acknowledged that no one in the kitchen was certified and that someone from an external dining service was handling ordering and menu planning, but this individual was not present at the facility daily. Observation and record review further confirmed that at the time of the survey, there were no certified dietary staff present or working in the kitchen. Facility documentation outlined a policy requiring at least one individual in the food service department to be certified in sanitation during hours of operation, with certification to be kept current and renewed as directed. Despite this policy, the facility did not have any certified staff available, potentially affecting all 74 residents residing in the facility.
Failure to Provide Sufficient and Competent Dietary Staff for Meal Service
Penalty
Summary
The facility failed to provide sufficient and competent dietary staff to safely and effectively carry out the functions of the food and nutrition service, as evidenced by repeated delays in meal service, inadequate meal preparation, and missing dietary accommodations. Observations showed that meal trays were not delivered in a timely manner, with breakfast and lunch service running significantly behind scheduled times. Food items were often served cold, missing condiments, and in some cases, were not prepared according to residents' dietary needs, such as pureed diets or supplements. The facility's own policy required meals to be served no more than 30 minutes after scheduled times, but this standard was not met on multiple occasions. Interviews with residents, family members, and staff confirmed ongoing issues with meal timeliness and quality. Residents reported receiving cold food, missing items, and frequent delays, sometimes waiting over an hour past scheduled meal times. Some residents received only peanut butter and jelly sandwiches and oatmeal for meals, and dietary tickets were not always followed, resulting in incorrect or incomplete trays. Family members and staff corroborated these accounts, noting that meal service was especially problematic after the dietary staff walked out, and that non-dietary staff had to step in to prepare and deliver meals, often without adequate training or resources. The administrator and other staff confirmed that all previous dietary staff left the facility, leading to a period where nurses and CNAs prepared meals. During this time, residents did not consistently receive required supplements or special dietary items, and meal service was late and incomplete. Staff also reported ongoing struggles with insufficient supplies and staffing, which continued to impact the quality and timeliness of meal service for all 74 residents in the facility.
Failure to Provide Timely Meals and Snacks per Resident Needs and Preferences
Penalty
Summary
The facility failed to ensure that meals and snacks were consistently available and served in accordance with residents’ needs, preferences, and care plans. Multiple residents, including those with diabetes and moderate cognitive deficits, reported not receiving bedtime snacks as documented in their care plans. Staff interviews confirmed that snacks were not always available, with some staff stating that the kitchen was locked after supper, preventing access to snacks for residents. Residents and their families also reported that snacks were not being distributed, and that residents who were unable to leave their rooms did not receive snacks at all. Additionally, the facility did not serve meals within the required timelines. Residents and family members reported that meals were frequently late, sometimes by over an hour, and that the timing of meal service was inconsistent. Observations confirmed that meal trays were not delivered to all areas in a timely manner, with some residents waiting significantly past scheduled meal times. Staff attributed these delays to issues such as broken kitchen equipment, lack of supplies, and staffing shortages. The facility administrator acknowledged that there was no formal snack policy and could not confirm that residents with diabetes received routine snacks as required. Staff interviews further revealed a lack of consistent process for providing snacks, with some staff unaware of procedures or not receiving education on snack distribution. The facility’s own policy outlined specific meal times, but these were not adhered to, as evidenced by both staff and resident accounts and direct observation of meal delivery times.
Failure to Maintain and Monitor Dish Machine Sanitizer Levels
Penalty
Summary
The facility failed to ensure proper functioning and monitoring of the dishwashing machine, which is necessary for the sanitation of dishware. During an interview, a dishwasher stated he was unfamiliar with the process for checking sanitizer levels and did not know where the test strips were located. When the test strips were found and used, they showed no color change, indicating that no sanitizer was present in the dish machine. Further observation revealed that there was no liquid in the line running from the sanitizer container to the dish machine, and attempts to purge the line were initially unsuccessful. Additionally, the dishwasher admitted to never documenting sanitizer readings on the dish machine log because the numbers did not make sense to him. The administrator was also unaware of when the dish machine was last checked or what the correct sanitizer reading should be. Review of the dish machine log showed inconsistent and potentially inaccurate documentation, with repeated entries of the same value and missing entries for several days. The facility's policy requires daily checks and proper documentation of sanitizer levels, which was not followed. At the time of the deficiency, 74 residents resided in the facility.
Failure to Maintain Resident Comfort and Provide Requested Personal Care
Penalty
Summary
Surveyors identified that the facility failed to honor and support resident self-determination by not keeping residents warm after showers and not providing nail care upon request for multiple residents. Observations revealed that shower rooms consistently measured around 71 degrees Fahrenheit, and staff were instructed not to adjust the thermostats. Several residents and their families reported that the shower rooms were cold, and residents were often returned to their rooms wet, inadequately dressed, or only covered by a towel, leading to prolonged discomfort. Staff interviews confirmed that residents frequently complained about the cold environment during and after showers, and that the shower chairs were uncomfortable, especially for those with pressure sores. One resident with significant medical issues, including dementia, pressure ulcers, and mobility deficits, reported receiving a cold shower late at night, being left with wet hair, and not being properly covered or dressed, resulting in her feeling cold all night. Family members corroborated these accounts, stating that complaints about the cold showers and improper handling had been communicated to facility administration multiple times. Other residents, including those with cognitive impairments and chronic illnesses, also expressed discomfort with the cold shower rooms and reported refusing showers to avoid being cold. Staff acknowledged that the shower rooms could be cold and that residents often voiced their discomfort. Additionally, the facility failed to provide timely nail care upon resident request. One cognitively intact resident repeatedly asked staff to trim his nails, which were observed to be long and dirty over several days. Despite reminders to both CNAs and LPNs, the resident's request was not fulfilled, and he stated that he avoided showers due to the cold, further impacting his ability to receive nail care. These failures demonstrate a lack of responsiveness to resident preferences and needs regarding personal care and comfort.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
The facility failed to provide timely incontinence care and adequate assistance with activities of daily living (ADLs), including showering and bathing, for six residents who required such support. Multiple residents with severe cognitive and physical impairments, including diagnoses such as neurocognitive disorder, dementia, hemiplegia, and muscle weakness, were documented as being dependent on staff for toileting hygiene and bathing. Care plans for these residents specified the need for regular incontinence checks, assistance with toileting, and scheduled showers or bed baths, yet these interventions were not consistently implemented. Observations, interviews, and record reviews revealed that residents were left in soiled clothing and bedding for extended periods due to insufficient staffing. Family members and staff reported that there were often not enough CNAs on duty to meet residents' needs, resulting in delays in providing incontinence care and missed opportunities for toileting. In several instances, residents were not offered or provided showers or bed baths for periods exceeding the facility's stated minimum frequency, and there was a lack of documentation to indicate that showers were refused or even offered. Staff interviews confirmed that short staffing was a persistent issue, making it difficult to complete scheduled care tasks, including two-hour bed checks and regular bathing. Documentation gaps were also identified, with missing or incomplete records for showers and refusals, and no facility policy in place for incontinence care or showering. Residents and their caregivers reported missed showers, prolonged periods without bathing, and inadequate assistance with toileting, all of which were corroborated by staff statements and review of care records. The facility's leadership was unable to explain the lapses in care or documentation, and acknowledged that the frequency of care provided did not meet the expected standards outlined in residents' care plans.
Failure to Follow Menus and Dietary Orders for Multiple Residents
Penalty
Summary
The facility failed to follow its posted menus and dietary orders for nine residents reviewed, resulting in multiple instances where residents did not receive the food items, condiments, or supplements as specified on their dietary tickets and care plans. Residents with various medical conditions, including chronic kidney disease, dementia, diabetes, malnutrition, and dysphagia, were affected. For example, several residents did not receive butter or jelly with their breakfast toast, corn tortillas, or butterscotch pudding with lunch, despite these items being listed on the menu and dietary tickets. In some cases, residents specifically expressed their desire for these missing items, but they were not provided. Interviews and observations revealed that the dietary staff did not consistently provide menu items as ordered, and there were reports of missing condiments, desserts, and even entire meal components. Staff and residents reported that the food served often did not match the dietary tickets, and that substitutions were not always made when items were unavailable. On one occasion, due to a staff walkout and lack of kitchen resources, residents were served peanut butter and jelly sandwiches and oatmeal instead of the planned menu, and some dietary supplements and double protein orders were not provided. Staff also reported ongoing issues with missing items and late food service following this event. The report includes statements from dietary staff, CNAs, and residents confirming that menu items were frequently omitted, and that communication between dietary and nursing staff was insufficient to ensure residents received their prescribed diets. The Registered Dietician stated that the menu should be followed and that substitutions of equal nutritional value should be made if items are unavailable, but this was not consistently done. The deficiency was observed through interviews, record reviews, and direct observation of meal service.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
Surveyors identified that the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for all 12 residents reviewed for food service. Multiple residents, all of whom were alert and oriented or cognitively intact, reported receiving cold, burnt, or unappetizing food on several occasions. Specific examples included cold coffee and French fries, burnt sausage, hard and dry toast, and oatmeal that was cold and congealed. Family members and staff corroborated these complaints, noting repeated issues with food being served cold or burnt, and a lack of condiments such as butter or jelly on trays. Direct observations by surveyors confirmed these reports. Food temperatures were measured using a calibrated thermometer, revealing that hot foods such as coffee, French fries, eggs, and oatmeal were served well below the facility's preferred minimum of 120 degrees Fahrenheit for palatability. For example, coffee was measured at 93°F and French fries at 89°F. Toast was frequently observed to be hard, burnt, and difficult to eat, and some trays lacked necessary accompaniments. Residents often refused to eat the food due to its poor quality and temperature, and some expressed frustration about the lack of timely alternatives when food was sent back. Staff interviews indicated ongoing challenges in the kitchen, including insufficient supplies and staffing, particularly during evenings and weekends. CNAs and the Dietary Manager acknowledged that residents had complained about the quality and temperature of food, and that the kitchen had struggled to deliver meals that met expectations. The facility's own policy requires periodic checks of food temperatures at the point of service, with a preference for hot foods to be at least 120°F, but this standard was not consistently met during the survey period.
Failure to Provide Resident-Preferred and Prescribed Dietary Options
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, intolerances, and preferences, as well as appealing options, for six out of seven residents reviewed for meal preferences and substitutions. Multiple residents with complex medical histories, including conditions such as diabetes, heart failure, dementia, and dysphagia, reported not receiving the food items listed on their dietary tickets, missing substitutions, and receiving items they specifically disliked or were not supposed to have. For example, one resident with dietary restrictions did not receive cranberry juice as ordered for several weeks, while another received rice despite a documented dislike, and another received beans despite a restriction against them. Several residents also reported not receiving requested or required items such as bananas, yogurt, or cereal, and noted that substitutions were often unavailable or significantly delayed. Staff interviews corroborated these resident reports, revealing that dietary staff shortages and supply issues contributed to the deficiencies. Staff described a period when all dietary staff walked out due to poor working conditions, including lack of gas for cooking and no air conditioning in the kitchen. During this time, non-dietary staff, including nurses and CNAs, prepared meals, which resulted in limited food options such as peanut butter and jelly sandwiches and oatmeal, with some residents missing supplements and double protein items. Staff also reported that food trays frequently lacked condiments and that substitutions and supplements were not consistently provided. The facility's dietary manager acknowledged ongoing issues with dietary tickets not being read carefully and missing items, and stated efforts were being made to address these problems. The facility's policy on dining experience emphasizes providing an exceptional dining experience that honors individual care plans and preferences, but observations, interviews, and record reviews demonstrated that these standards were not met during the survey period.
Failure to Provide Adequate Incontinence Supplies
Penalty
Summary
The facility failed to provide necessary incontinence supplies for three dependent, incontinent residents, resulting in the use of incorrect or inadequate products. Documentation for these residents showed that their care plans required specific interventions, such as the use of disposable briefs in the correct size, regular checks every two hours, and proper perineal care after incontinence episodes. However, interviews with residents and staff revealed that the facility repeatedly ran out of appropriately sized incontinence briefs, cleansing wipes, washcloths, and bed pads. Staff reported substituting smaller or larger briefs, using pull-ups instead of briefs, and resorting to makeshift alternatives such as pillowcases and blankets when standard supplies were unavailable. Residents affected by these shortages included individuals with significant cognitive and physical impairments, such as muscle weakness, unsteadiness, neurocognitive disorders, and complete dependence on staff for toileting hygiene. One cognitively intact resident reported discomfort from being provided with briefs that were too small, while staff described frequent leaks and skin contact with urine or feces when using ill-fitting or less absorbent products. Staff also noted that the use of pull-ups in place of briefs was not effective for residents with total incontinence, as these products did not provide adequate coverage or absorbency, leading to soiled bedding and increased risk of skin issues. Multiple CNAs and nurses confirmed that supply shortages had been ongoing for several weeks to months, with some reporting that the facility was out of certain supplies an average of three days per week. Staff consistently reported these shortages to administration, who sometimes responded by instructing staff to use alternative products or by stating that supplies were on back order. Despite these reports, administration was either unaware of the extent of the shortages or minimized their significance, attributing staff concerns to reluctance to retrieve supplies from laundry or misunderstanding the nature of grievances. The lack of a facility policy regarding towels was also noted during the investigation.
Failure to Timely Report Alleged Verbal Abuse to Administrator
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse were reported to the Administrator or Abuse Coordinator as required by policy. A resident with multiple medical conditions, including dementia, anxiety disorder, and major depressive disorder, reported to a CNA that an LPN had yelled at her and made derogatory remarks, causing the resident to become visibly upset and cry. The CNA did not report the allegation to the Administrator, stating she did not witness the incident and advised the resident to report it herself. The resident also reported similar concerns to another CNA on multiple occasions, who stated she did report it to the Administrator and Director of Nursing, but both denied awareness of any such allegations. The resident documented the alleged verbal abuse on a piece of paper, which included statements such as "choke on that," "it's all in your head," and "you are crazy," but did not include dates or times. Despite the facility's policy requiring immediate reporting of abuse allegations to the Administrator, the incident was not reported or investigated until a state surveyor brought it to the attention of facility leadership. Interviews with staff revealed inconsistent reporting and a lack of documentation or care plan focus related to abuse or behaviors for the resident. The Director of Nursing recalled staff mentioning the resident was upset with a staff member but did not recall any specific abuse allegations. The Administrator only became aware of the situation after being informed by the surveyor, at which point an investigation was initiated.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse involving a resident and a staff member were thoroughly investigated. The resident, who had multiple medical diagnoses including dementia, anxiety disorder, and major depressive disorder, was documented as cognitively intact and able to make reasonable decisions. Multiple certified nursing assistants (CNAs) and another resident reported that the resident had complained about an LPN being verbally abusive, using phrases such as "you are crazy" and "it's all in your head." The resident was visibly upset and reported being afraid of the staff member in question. Despite these reports, there was no documentation of a care plan focus area related to abuse or behaviors for this resident. Several staff members, including CNAs, stated that they either reported the allegations to the administrator or the director of nursing, or advised the resident to do so. However, both the administrator and the director of nursing stated they were unaware of any specific allegations of verbal abuse involving the staff member and the resident. The director of nursing recalled being told the resident was upset but did not receive details or the name of the alleged perpetrator. A grievance form was filed by the resident, indicating a staff concern, but lacked specific details about the incident. Follow-up documentation regarding the grievance was incomplete, with only one progress note available and no evidence of the required weekly follow-up meetings. The facility's abuse prevention policy requires immediate reporting and thorough investigation of alleged violations, with specific steps to prevent further abuse during the investigation. However, the investigation into the allegations was only initiated after the state surveyor brought the issue to the attention of the administrator and director of nursing. By that time, both the staff member accused and the resident had already been discharged. The lack of timely and thorough investigation, incomplete documentation, and failure to follow policy requirements led to the deficiency.
Failure to Ensure Residents Are Free from Significant Medication Errors Due to Late Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances of late medication administration for three residents with complex medical conditions. For one resident with diagnoses including diabetes, heart failure, and cerebral infarct, medications such as insulin, antidiabetics, diuretics, and anticonvulsants were repeatedly administered outside the prescribed time frames, sometimes several hours late. The resident confirmed that medications, including insulin, were often given late, particularly when agency nurses were on duty. Medication administration records corroborated these delays, and staff interviews revealed that workload, interruptions for resident care, and unfamiliarity with residents contributed to the late administration. Another resident with diabetes, dementia, and hypertension also experienced late administration of critical medications, including Humalog and Lantus insulin. Documentation showed that insulin doses intended to be given with meals or at bedtime were administered significantly later than ordered. Staff interviews indicated that high workload, the need to verify medications, and interruptions during medication passes were common reasons for these delays. The resident's blood sugar records did not show significant abnormalities during the review period, but the pattern of late administration was consistent. A third resident with chronic conditions such as COPD, chronic kidney disease, and repeated falls also received medications late, including gabapentin and Seroquel. This resident reported not always receiving medications as ordered. Multiple nursing staff, including RNs and LPNs, acknowledged that medications were sometimes administered late due to factors such as high resident acuity, the need to provide direct care, technical issues with electronic systems, and the challenge of managing large numbers of residents per shift. The facility's own medication administration policy emphasized the importance of timely administration, but adherence was not consistently maintained.
Failure to Provide Prescribed Dietary Supplements for Wound Healing
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including a stage 4 sacral pressure ulcer, severe protein-calorie malnutrition, and dysphagia, did not receive prescribed dietary supplements intended to support wound healing. The resident's care plan and physician orders included a regular diet with mechanical soft texture and specific supplements such as fortified foods, arginaid, prostat, multivitamins, and nutritional drinks. Despite these orders, direct observation revealed that the resident did not receive fortified cereal as ordered for breakfast, and the resident reported that the food provided often did not match what was listed on the dietary ticket. Interviews with staff indicated ongoing issues with the dietary department's process for providing supplements. Certified Nurse Aides reported difficulty obtaining missing supplements from dietary staff, who sometimes refused requests due to lack of time or unavailability of items. Dietary staff admitted they did not consistently read the bottom of dietary tickets where supplements and preferences were listed, citing time constraints during meal service. The facility administrator acknowledged awareness of these issues, and the registered dietitian confirmed that all recommended supplements should have been provided as ordered.
Failure to Maintain Functional Call System in Resident Bathroom
Penalty
Summary
A deficiency occurred when the facility failed to provide a functional call system in the bathroom of a resident who was at risk for falls and required assistance with toileting and transfers. The resident's care plan specifically included interventions to ensure the call light was within reach and functional, due to diagnoses such as unsteadiness, repeated falls, and generalized muscle weakness. Despite these documented needs, the call light in the resident's bathroom was not working for approximately two weeks. Staff interviews revealed that the LPN was aware of the non-functioning call light and had submitted a work order, but the Environmental Operations Director was unable to repair it and delayed notifying higher-level maintenance and administration. The Director of Nursing and Administrator were not made aware of the issue until the day of the survey, and there was no existing policy on call light systems in the facility. The maintenance job description required regular checks and repairs of nurse call systems, but this was not effectively carried out in this instance. Further investigation showed that the facility's call system was outdated, with no available replacement parts, and the outside technician was only able to partially restore functionality after being notified. The lack of timely communication and follow-through on maintenance responsibilities contributed to the prolonged period during which the resident did not have access to a working call system in the bathroom, despite being dependent on staff for toileting and transfers.
Failure to Maintain Clean and Sanitary Floors Due to Housekeeping Shortages
Penalty
Summary
The facility failed to maintain floors in a clean and sanitary manner, as evidenced by repeated observations of dried, dark-colored spills, sticky substances, and scattered debris such as torn paper and food particles on the floors of the 100 and 200 halls, as well as in the dining room. These unsanitary conditions persisted over multiple days, with the same spills and debris noted in the same locations during subsequent observations. A resident grievance was also filed regarding dirty floors in a resident's room, and a family member reported that the dining room floors had been consistently dirty over the past couple of months, not just immediately after meals. Interviews with staff, including the housekeeping supervisor, housekeepers, CNAs, and the administrator, revealed that the facility had been short-staffed in housekeeping for one to two months due to staff resignations. As a result, routine cleaning of common area floors, such as hallways and the dining room, was reduced from daily to every other day, and the remaining staff prioritized cleaning resident bathrooms, rooms, and shower areas. Additionally, the facility's floor cleaning machine was out of service, further hindering thorough cleaning. The facility did not have a housekeeping policy, although written housekeeping routes indicated that all floors should be swept and mopped daily.
Failure to Prevent Resident-to-Resident Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents involving residents with cognitive and physical impairments. In the first incident, a female resident with a history of cerebral infarction, major depressive disorder, muscle wasting, and impaired mobility, who was not cognitively intact, was sexually assaulted by another resident. The perpetrator, who also had cognitive impairment and behavioral issues, approached the female resident in the dining room, made an inappropriate sexual comment, and groped her breast. This event was witnessed by an LPN, who observed the inappropriate contact and intervened to separate the residents. The incident was substantiated as sexual misconduct based on consistent staff accounts and documentation in the facility's investigation report. In the second incident, another resident with cognitive impairment, a history of traumatic brain injury, and limited mobility was physically assaulted by the same resident involved in the first incident. The administrator witnessed the perpetrator strike the other resident on the head with an open hand in the dining room. The two residents then engaged in a physical struggle, which was immediately broken up by the administrator. Both residents involved in this incident had cognitive deficits and required assistance with activities of daily living. There were no obvious injuries reported as a result of the altercation. Both incidents were documented in the facility's investigation reports and were reported to the appropriate authorities, including the residents' power of attorneys, police, and medical doctors. The facility's abuse policy states that every resident has the right to be free from abuse and that abuse is prohibited. Despite this policy, the facility failed to prevent these incidents of sexual and physical abuse between residents with known behavioral and cognitive issues.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Accurately Reflect POLST Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's Practitioner Orders for Life-Sustaining Treatment (POLST) status was accurately reflected throughout the Electronic Health Record (EHR). The resident, who had diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and hypertension, was admitted with an advanced directive indicating Do Not Resuscitate (DNR) status in the admission record and order summary. However, the resident's signed POLST form indicated a preference for full cardiopulmonary resuscitation (CPR) in the event of unresponsiveness. During the survey, the administrator confirmed that the medical record should have matched the resident's POLST wishes for CPR to be performed, but the record incorrectly documented the resident as DNR. The facility's policy requires staff to verify code status using the medical record and to initiate CPR or notify the provider based on that documentation. The discrepancy between the POLST form and the EHR documentation led to the deficiency.
Failure to Provide Ordered Dietary Supplement
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident with severe cognitive impairment, multiple diagnoses including dementia, dysphagia, and feeding difficulties. The resident's care plan and dietary orders specified daily ice cream as a nutritional supplement, with fortified pudding and high-calorie liquid supplements also documented. Observations on two consecutive days showed that the resident was served meals without the ordered ice cream or a substitute supplement. The resident's meal card confirmed the requirement for a 4-ounce ice cream supplement, but this was not provided. Interviews with staff revealed that the facility had been out of the ice cream supplement for two days, and staff were unclear about what should be provided as a substitute. The dietary director acknowledged the shortage and stated that fortified pudding should have been given in place of ice cream, but this was not done. The resident's family, present during meals, also noted the absence of the supplement. The administrator confirmed that staff are expected to follow therapeutic diet orders.
Failure to Follow Infection Control Standards During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide urinary catheter care according to current infection control standards for a resident with severe cognitive impairment and multiple diagnoses, including neurocognitive disorder with Lewy bodies, Parkinson's disease with dyskinesia, and flaccid neuropathic bladder. The resident was dependent on staff for personal hygiene and had an order for catheter care every shift. During observed catheter care, the CNA placed wipes directly on the fitted sheet, used wipes to clean the resident's perineal area and catheter tubing, and repeatedly failed to perform hand hygiene or change gloves at appropriate times, such as after handling the trash can, after providing catheter care, and before emptying the catheter drainage bag. The CNA also used gloved hands to touch multiple surfaces, including the bathroom door, nightstand, and supply items, without changing gloves or performing hand hygiene between tasks. Additionally, the CNA returned a package of wipes from the resident's room to the supply cart in the hallway without performing hand hygiene, and the Director of Nursing (DON) confirmed that this was typical practice. The facility's policy required standard precautions, clean technique, and hand hygiene before and after glove use and handling of catheter supplies, but these procedures were not followed during the observed care. The DON stated that hand hygiene and glove changes were expected at several points during catheter care, but these expectations were not met during the observed incident.
Inadequate Supervision Leads to Falls and Elopement
Penalty
Summary
The facility failed to provide adequate assistance to prevent falls for two residents, resulting in significant injuries. One resident, with a complex medical history including cerebral infarction, hemiplegia, and repeated falls, fell from a tilt/recline chair in the dining room. The resident was left unattended while staff retrieved food, leading to a fall that caused a large intracranial hematoma, a left eyebrow laceration, and a left periorbital hematoma. The resident's care plan included interventions to prevent falls, such as using an anti-slip mat and not leaving the resident alone when sitting on the side of the bed. However, these measures were not effectively implemented, as the resident was left unsupervised in an upright position, contrary to the care plan's instructions. Another resident, diagnosed with dementia and severe cognitive impairment, fell from bed while receiving incontinence care. The resident, who had a history of falls and required one-person assistance for mobility, rolled off the bed during care, resulting in a forehead laceration requiring sutures and skin tears. The care plan included interventions such as using quarter side rails during care to prevent falls, but these were not in place at the time of the incident. The resident's bed was also raised higher than recommended during care, increasing the risk of falls. Additionally, the facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment and a history of elopement. The resident was last seen in the dining area before being found outside the facility by a staff member's spouse. The resident's care plan included interventions such as using a wander alert device and providing structured activities to prevent elopement. However, the resident was able to leave the facility unnoticed, indicating a lack of effective supervision and monitoring. The facility's elopement prevention measures, including door alarms and staff awareness, were insufficient to prevent the resident from leaving the premises.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three residents, as observed and reported by both residents and staff. Resident R5, who is cognitively intact, reported that his room was not kept clean, with a trash can that was consistently full and without a liner. His family member corroborated this, stating that the trash had not been emptied for several days. Observations confirmed the trash can was overflowing with soda bottles stacked on top. Resident R6, who is alert and oriented, expressed dissatisfaction with the cleanliness of her room upon arrival, noting dust behind the door and in her closet, and a mold-like substance around the toilet ring. She had to request the housekeepers to clean these areas. Resident R7, also alert and oriented, reported that his room was not cleaned well, with trash cans often full and the table not cleaned off. A friend who visits regularly confirmed these observations, stating he often had to clean the table himself. Staff members, including CNAs and a registered nurse, reported similar issues with housekeeping, noting overflowing trash cans, dirty floors, and inadequate bathroom cleaning. The facility's cleaning chart outlines a specific cleaning method, but it appears these procedures were not consistently followed, leading to the deficiencies observed.
Failure to Provide Twice-Weekly Showers for Resident
Penalty
Summary
The facility failed to provide twice-weekly showers for a resident with cerebral palsy and diabetes type 2, who requires partial or moderate assistance for bathing and hygiene. The resident's care plan indicated the need for staff assistance with bathing, yet documentation showed the resident received only one shower per week on multiple occasions. Interviews with the resident's family member and CNAs revealed inconsistencies in the shower schedule, with the family member expressing concerns about the resident's hair appearing dirty and greasy. The Director of Nurses confirmed the expectation for residents to receive two showers weekly, with hair washing included unless otherwise preferred by the resident. However, there was no documentation to support claims of the resident refusing showers or hair washing. The facility lacked policies related to bathing, ADL care, or hair care, as confirmed by the Administrator, contributing to the deficiency in providing adequate care for the resident.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident with a history of multiple falls. The resident, who has Alzheimer's Disease, Type 2 Diabetes, and mobility issues requiring a wheelchair, experienced numerous falls from self-transfers over several months. Despite these incidents, the resident's care plan did not include new interventions for falls that occurred on specific dates. The facility's fall policy mandates that after any fall, an occurrence report should be completed, causal factors identified, and interventions implemented with updates to the care plan. However, the care plan for this resident was not updated with new interventions following several falls, as confirmed by the Registered Nurse responsible for care planning.
Deficient Catheter Care for Resident
Penalty
Summary
The facility failed to provide catheter care in accordance with current standards of practice for a resident with a Foley catheter. The resident, who has a history of cerebral infarction, spastic hemiplegia, and dysphagia, was observed receiving catheter care that did not adhere to the facility's documented procedures. Specifically, during the catheter care, the CNA did not separate the labia or cleanse the urinary meatus, which are required steps according to the facility's catheter care guidelines. The resident's care plan included specific instructions for catheter care every shift and as needed, with a focus on monitoring for signs and symptoms of urinary tract infections. Despite these instructions, the CNA performing the care did not follow the proper technique, as confirmed by the Interim ADON and the DON, who both stated that they would expect the labia to be separated during catheter care. The CNA later admitted to not performing the procedure correctly due to nervousness.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer a resident's tube feeding in accordance with the physician's orders. The resident, identified as R47, was admitted with diagnoses including cerebral infarction, gastrostomy status, and cognitive communication deficits. The care plan indicated that R47 required tube feeding, with specific orders for Nutren 2.0 continuous feeding at a rate of 40 ml per hour and 120 ml water flush every two hours. However, observations on multiple occasions revealed that the feeding pump was infusing at a rate of 30 ml per hour, contrary to the prescribed 40 ml per hour. Interviews with staff, including an LPN and the Director of Nursing, revealed that they were unable to recall the correct tube feeding order for R47. Upon review of the electronic health record, it was confirmed that the infusion rate should have been 40 ml per hour. The facility's protocol for enteral tube medication administration emphasized the importance of verifying the caloric content per milliliter before administration to ensure the correct dosage is given, which was not adhered to in this case.
Failure to Label Insulin Vials with Opening Dates
Penalty
Summary
The facility failed to label insulin vials and insulin pens with the date of opening for two residents, leading to a deficiency in medication storage practices. Resident 49, who was admitted with diagnoses including type 2 diabetes mellitus and epilepsy, had orders for insulin Lispro and insulin Glargine. On a specific date, it was observed that both insulin types were open and lacked an opening date. A Licensed Practical Nurse (LPN) confirmed the absence of opening dates and stated that the insulin vials would need to be disposed of and replaced. Similarly, Resident 52, admitted with conditions such as acute kidney failure and type 2 diabetes mellitus, also had orders for insulin Lispro and insulin Glargine. These insulin vials were found open without opening dates during an inspection. The same LPN verified this issue and indicated that the vials would have to be discarded and new ones obtained. The facility's policy required medications to be stored securely and properly, following manufacturer recommendations, which include disposing of opened insulin after 28 days.
Failure to Provide Peritoneal Dialysis
Penalty
Summary
The facility failed to provide peritoneal dialysis treatments for a resident (R1) who required such services. R1 was admitted to the facility with a diagnosis of End Stage Renal Disease and a need for peritoneal dialysis. However, upon arrival, R1 did not have the necessary dialysis supplies, and the facility did not have the supplies or adequately trained staff to assist with the dialysis treatment. Despite being aware of R1's dialysis needs, the facility did not ensure that the supplies were available or that the staff were properly trained to assist R1 with her peritoneal dialysis. R1's condition deteriorated due to the lack of dialysis treatment. The facility's staff attempted to contact R1's family to obtain the necessary supplies, but there were delays in getting the supplies to the facility. R1 experienced confusion and lethargy due to missed dialysis treatments and was eventually sent to the hospital for evaluation. The hospital records indicated that R1 had not received peritoneal dialysis for at least two days, leading to a change in dialysis modality to hemodialysis during the hospital stay. Interviews with facility staff revealed that there was a lack of proper training and preparedness to handle peritoneal dialysis for R1. The Director of Nursing (DON) admitted that the staff had not been trained on a peritoneal dialysis machine by certified dialysis staff. The facility's failure to ensure the availability of supplies and adequately trained staff resulted in R1's hospitalization and a change in dialysis treatment modality.
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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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