Miller Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kankakee, Illinois.
- Location
- 1601 Butterfield Trail, Kankakee, Illinois 60901
- CMS Provider Number
- 145843
- Inspections on file
- 25
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Miller Health Care Center during CMS and state inspections, most recent first.
A resident with quadriplegia and extensive ADL needs, including dependence for transfers, was transferred using a full mechanical lift by a single CNA, contrary to facility policy requiring two staff for such transfers. During the transfer to a motorized wheelchair, the resident began sliding forward, and the CNA left the room to seek help. An LPN later observed the resident sliding out of the chair with legs extended on the floor, with the top of the sling attached to the lift but the bottom portion not under the resident or attached. The CNA stated she had performed the lift alone and attempted to reposition the resident in the chair with the sling, which then came out from under the resident, and later told the family she could not find anyone to assist.
A resident admitted with acute respiratory failure and hypoxia had no documented code status, advance directive, nursing assessment, or vital signs in the EMR for approximately 16 hours after admission. When a CNA could not obtain the resident’s BP or heart rate, an agency RN did not immediately assess the resident and continued a med pass, later finding the resident unresponsive and leaving the bedside to seek another RN, while incorrectly stating the resident was DNR. Staff at the bedside were unable to locate any code status in the chart, and CPR was initiated only after a Respiratory Therapist confirmed the absence of a pulse and breathing. The agency RN called a non-emergency transport number instead of 911, and 911 was ultimately called by a CNA using a personal phone, with EMS confirming only that single 911 call. Subsequent review showed the resident’s hospital orders listed a partial code status that had not been entered into the facility record, and leadership confirmed that code status should be obtained and entered at admission and that CPR should be started immediately when no DNR order is present.
Surveyors found that staff failed to promptly assess and notify providers of significant changes in condition for three residents. After a fall with head impact, a resident developed new right thigh and hip pain and an antalgic gait documented over several days, but no provider was notified until severe pain and inability to move the foot led to hospital transfer and diagnosis of a comminuted periprosthetic hip fracture. Another resident with known GI pathology had repeated episodes of dark, bloody emesis and dark stools reported by a CNA, yet documentation only reflected nausea and PRN ondansetron, with no provider notification of hematemesis or melena until critical lab values prompted hospital transfer and blood transfusions. A third resident experienced a witnessed fall with back impact, developed persistent and increasing low back and hip pain requiring repeated PRN analgesics and noted by therapy, but the physician or NP was not notified of this post‑fall pain until hospital evaluation revealed an acute L2 compression fracture, contrary to facility policy and provider expectations for immediate reporting of such changes.
A resident admitted for rehab after a hip/pelvic fracture, with multiple risk factors including prior falls, gait abnormality, dizziness, cognitive deficits, and recent hospitalization, was assessed by an agency LPN as high fall risk, but no fall precautions or fall care plan interventions were implemented despite prompts in the EHR. Later, while confused and attempting to get up to retrieve clothes, the resident was found on the floor by an LPN, with no documented fall precautions in place. The resident was transferred to the ED, where imaging showed an acute right intertrochanteric hip fracture, and leadership and the NP confirmed that required fall precautions for a high fall risk resident had not been initiated.
A resident with a care plan and MD order for a mechanical soft diet with nectar-thick liquids, due to risks including coughing/choking episodes and need for feeding assistance, was observed receiving a lunch tray that included potato chips, which are not mechanically soft. The dietician confirmed chips are inappropriate and pose a chewing and choking risk for this diet level. The dining room supervisor stated she transcribed the family’s menu request for chips without recognizing the conflict with the ordered diet, and the dining room service director, who is responsible for double-checking trays against diet orders, acknowledged she missed the error. This resulted in the resident not receiving food in the prescribed mechanical soft form, contrary to facility policy and the resident’s care plan.
A resident with severe cognitive impairment underwent a wound biopsy without consent from their family, who were responsible for making care decisions. Staff proceeded with the procedure after the resident indicated agreement, but interviews and record review confirmed the resident was not capable of providing consent and the family was not consulted.
The facility failed to provide timely incontinent care to five residents, resulting in deficiencies. One resident with severe cognitive impairment was reported unclean by EMS, while another with mild cognitive impairment was found with a urine-soaked brief. A third resident was not changed due to staff being busy, and a fourth was found wet despite his wife's efforts. A fifth resident with a colostomy was also found with a soaked brief. The facility's policy requires checks every two hours, which was not followed.
A resident with multiple health issues experienced unmanaged pain during a bed bath and wound care. Despite visible signs of distress and available pain medications, staff did not offer relief or pause procedures. The resident's pain was not addressed until prompted, contrary to facility policy.
The facility failed to provide properly pureed carrots for residents requiring a pureed diet. Four residents with various diagnoses, including dementia and dysphagia, were affected. A cook prepared the carrots without following recipes, resulting in a chunky texture. Despite initial approval by the cook and dietary manager, further tasting revealed the carrots were not smooth, violating the facility's policy on pureed foods.
The facility failed to follow standard infection control practices, including hand hygiene and the use of personal protective equipment, during care for several residents. Instances included CNAs not wearing gowns during high-contact care, improper handling of soiled linens, and a urinary catheter bag placed on the floor. An LPN also did not follow proper glove-changing protocols during wound care.
A resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's and ESBL, was not provided with necessary assistance for ADLs. Despite expressing a need for personal care, the resident was observed with unshaven appearance, overgrown nails, and unchanged clothing, contrary to the facility's policy requiring daily hygiene care. The DON confirmed that such care should be provided daily, regardless of isolation status.
The facility failed to offer and administer pneumonia vaccines to residents, as shown by the lack of documentation for three residents. Interviews revealed confusion among staff about the vaccination process and documentation. The facility's policy to vaccinate residents aged 65 and older was not effectively implemented.
The facility failed to offer the COVID-19 vaccine to two residents, with no documentation of offers or refusals. Staff interviews revealed confusion about the vaccine offering process, and the facility's policy on encouraging vaccinations was not followed.
The facility did not inform residents of their right to organize and participate in resident council meetings, affecting all 92 residents. During a group meeting, several alert and oriented residents, including the newly elected president of the Resident Council, were unaware of this right and expressed a desire for such meetings. The Activity Director noted past unsuccessful attempts to organize meetings and a lack of policy on resident councils, with no documentation of meetings in the past six months.
Three residents reported long wait times for call light responses, with documented delays ranging from 15 to 73 minutes. Despite raising these concerns during resident council meetings, there was no documentation of investigations or actions taken. The facility lacked a policy on call light response times, although staff were expected to respond within 15 minutes.
A resident with limited mobility and functional quadriplegia was found with significant stool and urine on his body and bedding, indicating a failure to provide timely incontinence care. The CNA admitted to checking residents every 2 to 3 hours, despite the resident's need for more frequent checks. The facility administrator acknowledged multiple complaints about delayed assistance.
The facility failed to provide adequate skin assessments for three residents, leading to deficiencies in care. One resident's wounds were not assessed upon admission, another resident's daily evaluations were not performed, and a third resident was often left in the same position for extended periods, leading to skin redness and potential breakdown.
Failure to Provide Two-Person Assist During Full Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring two staff members for a full mechanical lift transfer. A cognitively intact resident with quadriplegia C6-C7 incomplete, post laminectomy syndrome, muscle wasting, chronic venous insufficiency, cellulitis of the right lower leg, and a stage 4 sacral pressure ulcer required extensive assistance with ADLs, including dependence on staff for transfers. The resident’s MDS showed dependence for transfers, and the facility’s mechanical lift policy dated January 2026 stated that two staff members are required during a full body lift transfer. The facility’s Restorative RN and Interim DON both stated that the expectation is for two staff to assist when using the full mechanical lift. The facility’s fall incident reports showed the resident had a witnessed fall on February 6, 2026, during a transfer at the bedside when the resident slid forward in the chair. A CNA’s written statement documented that the CNA transferred the resident to a motorized wheelchair and the resident started to slide out, leading the CNA to leave the room to get help. An LPN later reported seeing the CNA request assistance and, upon entering the room, observed the resident sliding out of the chair with legs extended on the floor. The mechanical lift was present, with the top of the sling attached to the lift hooks, but the bottom of the sling was not underneath the resident and not attached to the lift. The LPN reported that the CNA stated she had transferred the resident from bed to chair using the full mechanical lift by herself and had attempted to move the resident up in the chair with the sling when it came out from underneath the resident. The LPN also reported that, in the presence of the resident’s daughters, the CNA stated she could not find anyone to assist with the transfer.
Failure to Assess Change in Condition, Call 911, and Document Code Status for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess a resident when a CNA was unable to obtain vital signs and the failure to ensure the resident’s code status was documented and available in the medical record. Around 6:30 AM, a CNA informed an agency RN that she could not obtain a blood pressure or heart rate for the resident. The agency RN stated she continued passing morning medications to other residents and did not immediately assess the resident. Approximately an hour later, around 7:45 AM, the agency RN went to administer medications to the resident, found the resident unresponsive, and was unable to obtain vital signs or detect a heartbeat with a stethoscope. After finding the resident unresponsive, the agency RN left the bedside to locate another RN working on a different hall and told her she thought the resident had expired and that the resident was DNR. The second RN went to the resident’s room, observed the resident to be pale with bluish lips but still warm, and confirmed there was no heartbeat or carotid pulse. She was then called away to attend to her own residents and left the unresponsive resident. Around 8:00 AM, the Social Service Director walked past the resident’s room, saw the resident slumped to the side in bed with staff present, and heard that staff could not obtain vital signs. He then asked a Respiratory Therapist to check the resident’s code status in the electronic record. The Respiratory Therapist found no code status orders in the chart, went to the room, assessed that the resident was not breathing and had no pulse, and initiated chest compressions. An LPN/Acting ADON then entered and took over compressions while the Respiratory Therapist applied an AED and began ventilations with a bag-valve mask. During the code response, a Dietary Aide/CNA was called into the room to assist with CPR and completed two rounds of chest compressions. She reported that the Respiratory Therapist and Acting ADON were trying to determine who the resident’s nurse was and why 911 had not been called. The agency RN then entered and stated she had called a universal ambulance transport number and was unsure whether 911 should be called for an unresponsive patient. The Dietary Aide/CNA then called 911 from her personal phone; EMS records show 911 was called at 8:33 AM, with paramedics arriving shortly thereafter and taking over resuscitative efforts until the resident was pronounced deceased. The Assistant EMS Coordinator confirmed that only one 911 call was received for this event, from the Dietary Aide/CNA. The resident had been admitted to the facility approximately 16 hours before the code event with a primary diagnosis of acute respiratory failure with hypoxia. The facility face sheet and physician order sheet contained no advance directive or code status, and there was no documented nursing assessment or vital signs for the resident after admission. The agency RN reported she was the admission nurse and that another LPN had taken the hospital report, which included the resident’s code status, but the agency RN did not remember what that status was and acknowledged it was the admission nurse’s responsibility to enter code status into the electronic record. The Admissions Director later stated that the hospital chart showed the resident was a partial code, with orders for no mechanical ventilation with intubation, selective cardio resuscitation, no chest compressions, and no defibrillation/cardioversion, but this was not discovered until after the resident’s death. The Administrator and DON confirmed that the resident’s code status should be obtained and entered into the system immediately upon admission so staff know how to proceed in an emergency, and that if no code status is present, staff are expected to initiate CPR immediately when a resident is found unresponsive.
Removal Plan
- Completed an audit of resident code status to ensure all current residents had a code status.
- Provided education to all nursing staff on code status and emergency response expectations.
- Ceased any practice of delaying CPR due to verbal assumptions of DNR status.
- Implemented a directive that all residents will be treated as full code unless a valid physician DNR order is present and accessible in the medical record.
- Completed a 100% audit of all current resident charts to verify presence of physician code status orders.
- Completed an audit to ensure DNR status was accurately reflected on nursing shift-to-shift reports and matched the DNR status in the chart.
- Placed an emergency code status roster at all nurse's stations for rapid access.
- Updated the change in condition policy to require nursing staff to immediately assess when vital signs cannot be obtained and not delay escalation.
- Nursing leadership to educate all staff (including agency) on the Do Not Resuscitate Order Policy, CPR Policy, and Change in Resident Condition Policy, and educate remaining staff prior to their next worked shift.
- Reeducated nursing staff on rooming responsibility for new residents including clinical assessment completion within 2 hours of arrival and completion of a move-in note, with daily auditing by the DON.
- Implemented an admissions checklist including DNR status to validate patient wishes prior to arrival.
- Director of Sales and Marketing to audit daily.
- Implemented an immediate requirement for licensed nurse assessment without delay upon inability to obtain vital signs or change in condition.
- Reeducated staff that CPR must be initiated unless a physician DNR order is confirmed.
- Verified all current agency staff have completed the orientation checklist prior to taking an independent patient assignment.
- Planned a QAPI action plan including audits of admission code status completion upon admission, admission checklist with code status known prior to admission, nursing assessment completion within 2 hours of admission by admitting nurse, nursing completion of move-in note upon admission, agency checklist completion prior to taking a full assignment, and weekly mock CPR code completion on each shift.
Failure to Notify Providers of Post‑Fall Pain and GI Bleeding Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to assess and notify providers of residents’ changes in condition following falls and gastrointestinal symptoms, resulting in delayed treatment for pain and injury. One resident with a history of mesothelioma, peripheral vascular disease, neoplasm-related pain, osteoarthritis, and a prior periprosthetic right hip fracture sustained a witnessed fall in the day room, striking his head on a table and being sent to the hospital for evaluation of a head injury. The hospital emergency department documentation from that visit reflected only a head injury complaint and a negative head CT, with no other injuries identified. After the resident returned to the facility, there was no documentation of his return, and the EMR showed no provider notification regarding new right thigh or hip pain that began the day after the fall. In the days following this fall, multiple nursing and therapy notes documented new and ongoing right thigh and right lower extremity pain, as well as a change in gait. Therapy staff observed an antalgic gait and a pain score of five out of ten in the right lower extremity, and nursing documentation recorded repeated complaints of right thigh pain with increasing pain scores. Despite these findings, there was no documentation that the physician or nurse practitioner was notified of the new pain or gait change until several days later, when the resident complained of right hip pain and inability to move his right foot. At that time, the nurse reviewed the prior hospital record, noted that no hip x‑ray had been done, paged the physician, and the resident was sent back to the hospital, where imaging revealed an acute comminuted periprosthetic hip fracture requiring operative fixation. Another resident with acute kidney failure, ESRD, malignant neoplasm of the colon and rectum, melena, and GI hemorrhage experienced nausea and vomiting at the facility. A CNA reported that during one night the resident vomited three times with dark red emesis containing blood and clots and had a dark bowel movement, and stated that this was reported to the nurse. The nurse on that shift later stated she was not told about vomiting blood or black stools. Subsequent nursing documentation noted nausea and a request for anti‑nausea medication, and the resident later received ondansetron for nausea/vomiting, but the EMR contained no documentation that the provider was notified of vomiting blood or black tarry stools. A later lab draw showed a critically low hemoglobin and hematocrit, and the resident was sent to the hospital, where records described persistent vomiting of blood since transfer to the facility, low hemoglobin, and a plan for admission, GI consult, endoscopic evaluation, and blood transfusions. A third resident with multiple diagnoses including surgical aftercare following digestive surgery, pneumonia, muscle wasting, muscle weakness, cognitive communication deficit, difficulty in walking, and chronic kidney disease sustained a witnessed fall while being transferred with a walker. The CNA guided the resident to the floor, and the resident was assisted back into a recliner before the RN assessed her. The RN later acknowledged she should have assessed the resident before lifting her from the floor. The resident initially denied pain but had pink marks on the middle of her back and right upper shoulder after reportedly hitting her back on a dresser. The nurse did not consider these marks an injury and did not notify the physician, although she administered acetaminophen and later tramadol for back and hip pain that same evening and on subsequent days. Therapy staff documented back pain rated five out of ten the day after the fall and ongoing pain with movement, and nursing documentation later described increasing low back and right hip pain since the fall, leading to orders for imaging and eventual hospital evaluation. Hospital imaging ultimately showed an acute L2 compression fracture. The EMR contained no documentation that providers were notified of the resident’s increasing back and lower extremity pain after the fall, despite repeated administration of PRN pain medications and therapy reports of pain. Across these three residents, interviews with nursing, therapy staff, the DON, and medical providers confirmed expectations that new pain, changes in gait, vomiting blood, black tarry stools, and injuries or suspected injuries after falls should be promptly assessed and reported to the provider. The facility’s own Change in Resident’s Condition policy required nursing staff to report significant changes, including persistent vomiting and falls or other injuries, to the physician and responsible family member. The documented failures to assess promptly, to recognize and treat post‑fall injuries as potential injuries, and to notify providers of new or worsening pain and gastrointestinal bleeding symptoms constituted the basis of the cited deficiency.
Failure to Implement Fall Precautions for High-Risk Resident Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement fall precautions for a resident who was identified as high risk for falls upon admission. The resident was admitted with a primary diagnosis of left pubis fracture and additional conditions including unsteadiness on feet, gait and mobility abnormalities, cognitive communication deficit, dizziness, osteoarthritis, and a history of falls. An agency LPN completed an admission Fall Risk Evaluation that documented recent falls, incontinence, predisposing conditions, recent hospitalization, and use of medications increasing fall risk, resulting in a high fall risk score. Despite this, no fall precautions or interventions were triggered or implemented from this evaluation, and no fall risk care plan or interventions were documented in the at-risk plan prior to the incident. On the date of the fall, the LPN caring for the resident reported hearing the resident yelling and found her on the floor at the foot of the bed, lying on her right hip and supporting herself with her right hand. The resident was confused, attempted to stand and walk to her closet, and stated she was trying to get her clothes to go home. The LPN stated she was not aware of any fall precautions in place for the resident at that time. Subsequent review by the acting ADON confirmed that the nurse who completed the fall risk assessment did not implement any fall precautions when prompted by the electronic health record, and that no fall interventions were in place before the fall. The NP stated that facility protocol requires fall precautions for any resident assessed as high fall risk, which should have been done for this resident. Following the fall, an emergency room X-ray documented an acute right intertrochanteric hip fracture.
Failure to Provide Ordered Mechanical Soft Diet Consistency
Penalty
Summary
Surveyors identified a deficiency in which a resident did not receive a mechanically soft diet as ordered by the physician. During a lunch observation, the resident was seen being fed a meal that included sautéed broccoli, mandarin oranges, a chicken salad sandwich, potato chips, and nectar-thick root beer. The resident’s POS documented an order for a regular diet with mechanical soft texture and nectar/mildly thick liquid consistency. The resident’s care plan, developed due to risk for altered nutrition/hydration status related to frequent propelling, coughing/choking episodes, increased lethargy, and need for feeding assistance, included an intervention to provide and serve the diet as ordered, specifying mechanical soft foods and nectar-thick liquids. The facility’s dietician stated that potato chips are not appropriate for a mechanical soft diet because of their crunchy texture and the associated risk of difficulty chewing and choking, and confirmed that the resident should not have received potato chips. The dining room supervisor reported that the resident’s daughter completed the menus and that she transcribed the request for chips without realizing it conflicted with the mechanical soft diet order. The dining room service director, who serves as a second check in the kitchen to ensure meals match prescribed diets, acknowledged that she missed the incorrect plating of the resident’s tray. Both dietary staff members agreed that potato chips should not have been served to a resident on a mechanical soft diet. The facility’s policy on oral nutrition and feeding assistance requires that residents receive nutrition and hydration in accordance with the care plan, diet order, swallowing precautions, and interdisciplinary guidance.
Failure to Obtain Consent for Wound Biopsy in Cognitively Impaired Resident
Penalty
Summary
The facility failed to obtain proper consent prior to performing a wound biopsy on a cognitively impaired resident. The resident, who had severe cognitive impairment as documented in the Minimum Data Set, was admitted with multiple diagnoses including hemiplegia, aphasia, and respiratory failure. The wound care physician performed a biopsy on the resident's left shoulder after explaining the procedure to the resident, who reportedly indicated agreement by shaking his head and giving verbal consent. However, there was no documentation that the resident's family, who were responsible for making care decisions, were consulted or provided consent prior to the procedure. Interviews with facility staff confirmed that the resident was not capable of making decisions or providing consent for care or procedures. The social worker stated that the family had expressed a desire to be present for such decisions, and the family member confirmed that neither the resident's wife nor daughter was contacted for consent before the biopsy was performed. Review of the electronic medical record showed no documentation of consent from the family for the procedure.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to five residents, leading to deficiencies in their care. One resident, a male with severe cognitive impairment, was reported by EMS to be unclean when picked up for a hospital visit, and it was later revealed he had a gastrointestinal bleed. Another resident, a female with mild cognitive impairment, was found with a urine-soaked brief and had not been changed since the previous night, despite her care plan requiring checks every two hours. A third resident, also with mild cognitive impairment, was observed with a urine-soaked brief, and the CNA admitted not having had the chance to change her. A fourth resident, a male with intact cognition, was found wet and had not been changed, with his wife providing a urinal in the meantime. His care plan included interventions for the risk of impaired skin integrity. The fifth resident, a male with a colostomy, was found with a soaked brief, having been changed earlier in the morning. The facility's policy, approved in July 2024, mandates that residents with incontinence issues be kept clean, dry, and comfortable, with checks every two hours, which was not adhered to in these cases.
Failure in Pain Management During Resident Care
Penalty
Summary
The facility failed to manage a resident's pain effectively during routine care activities, specifically during a bed bath and wound care. The resident, who has multiple diagnoses including diabetes mellitus with neuropathic arthropathy, pressure ulcers, morbid obesity, and end-stage renal disease, was observed to be in significant pain during these procedures. Despite the resident's complaints of pain, flinching, and crying out during the bed bath, the Certified Nursing Assistants (CNAs) did not offer any pain medication or pause the procedure. The resident's right foot was noted to be particularly tender, and an object was removed from between the toes, yet no pain relief was provided. During the subsequent wound care session, the wound care nurse was informed of the resident's pain but continued with the treatment without addressing the pain. The resident continued to express pain during the dressing of pressure ulcers and the examination of the right foot. The Medication Administration Record indicated that pain medications were available, including acetaminophen and Tramadol, but the latter had not been administered since May, well before the incident. The Director of Nursing later confirmed that staff should notify the assigned nurse if a resident is in pain and pause any procedure causing pain until relief is provided, which was not adhered to in this case.
Failure to Provide Properly Pureed Carrots for Residents
Penalty
Summary
The facility failed to ensure that carrots were prepared with a smooth consistency for residents requiring a pureed diet. This deficiency was observed in four residents who had various diagnoses, including vascular dementia, dysphagia, Alzheimer's disease, dementia, traumatic brain injury, cerebral atherosclerosis, and metabolic encephalopathy. Each of these residents had active orders for a regular diet with pureed texture, indicating the necessity for food to be prepared in a form that meets their dietary needs. On the day of observation, a cook was seen preparing pureed meals without following any recipes. The cook blended a large quantity of carrots with a small amount of thickener, resulting in a mixture that was chunky and not smooth. Despite being aware of the issue, the cook and the dietary manager initially deemed the carrots ready for serving. Upon further tasting, both acknowledged the carrots were not properly pureed, with the dietary manager noting they needed more cooking and the cook admitting they required additional blending. The facility's policy on modified texture foods, which mandates a smooth texture for pureed foods, was not adhered to in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to standard infection control practices during the provision of care to several residents. In one instance, a CNA removed gloves and sanitized her hands but then carried a resident's soiled gown with bare hands through the hallway without using a plastic linen bag. Another incident involved a CNA who did not perform hand hygiene after removing gloves and before assisting a resident with clothing and transferring them back to a wheelchair. In another case, CNAs did not wear gowns while preparing a resident for a bed bath, despite the resident being on Enhanced Barrier Precautions (EBP) due to multiple pressure ulcers and a hemodialysis access port. Similarly, a wound care nurse began preparing for a dressing change without donning a gown, contrary to the facility's EBP policy. Additionally, a CNA placed a urinary catheter bag on the floor during a resident's repositioning, and later handled the bag without gloves, which is against the facility's policy. A Licensed Practical Nurse (LPN) failed to follow proper hand hygiene and glove-changing protocols during wound care for a resident with multiple pressure ulcers. The LPN did not sanitize hands between glove changes after applying treatment with a gloved hand, which is required by the facility's standard precautions policy. These deficiencies highlight lapses in infection control practices, particularly in hand hygiene and the use of personal protective equipment during resident care.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to a resident, identified as R436, who required such assistance. R436 was admitted to the facility on July 10, 2024, with diagnoses including generalized muscle weakness, Alzheimer's with late onset, dementia, polyneuropathy, and ESBL in his urine, necessitating contact isolation. Observations revealed that R436 was not receiving adequate personal care, as evidenced by his unshaven appearance, overgrown and jagged fingernails, and unchanged clothing over consecutive days. Despite expressing a desire for a shave and nail care, these needs were not addressed in a timely manner. The facility's policy mandates daily personal care, including hygiene and grooming, regardless of a resident's isolation status. However, R436 was observed wearing the same clothes with a noticeable odor and unkempt hair, indicating a lack of adherence to this policy. The Director of Nursing acknowledged that residents should receive daily hygiene care, including oral care, bathing, shaving, nail care, and clean clothing. The failure to provide these services to R436 highlights a deficiency in the facility's compliance with its own care standards.
Failure to Administer Pneumonia Vaccines
Penalty
Summary
The facility failed to offer and administer pneumonia vaccines to both new and current residents, as evidenced by the review of medical records and staff interviews. Specifically, three residents, identified as R29, R53, and R286, did not receive the necessary pneumonia vaccinations. R29's medical record did not show any evidence of receiving or being offered a pneumonia vaccine since admission. Similarly, R286's record lacked documentation of any pneumonia vaccine being offered or administered. R53, who had previously received the pneumococcal conjugate 13-valent vaccine before admission, was eligible for the PPSV-23 vaccine one year later, but there was no record of it being offered. Interviews with facility staff revealed a lack of clarity and consistency in the process of offering and documenting pneumonia vaccinations. The Vice President of Post-Acute Care was unable to locate vaccination records for R29 and R286. The Infection Prevention Nurse stated that vaccines should be offered to all new admissions and documented accordingly, including any refusals. However, the Assistant Director of Nursing was unsure about who was responsible for offering the vaccines and what vaccines were available. The Director of Nursing indicated that it was expected for all nurses to offer the vaccines upon admission, but the documentation process was not consistently followed. The facility's policy, last revised in December 2019, aimed to reduce pneumococcal incidence by vaccinating residents aged 65 and older, but the implementation of this policy was evidently lacking.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to new and current residents, specifically affecting two residents, R286 and R437, out of a sample of 19. R286 was admitted to the facility and had previously received one dose of the COVID-19 vaccine, but there was no documentation indicating that the facility offered the vaccine upon or after admission. Similarly, R437's medical record showed no evidence of receiving any COVID-19 vaccines, nor was there documentation that the vaccine was offered. Interviews with facility staff revealed inconsistencies and confusion regarding the process of offering the COVID-19 vaccine. The Vice President of Post-Acute Care could not locate additional vaccine records for R286. The Infection Prevention Nurse stated that vaccines should be offered to all new admissions and documented accordingly, including any refusals. However, the Assistant Director of Nursing was unsure who was responsible for offering the vaccine and mentioned logistical challenges in obtaining the vaccine. The Director of Nursing indicated that it was expected for all nurses to offer the vaccine to new admissions, with documentation required for offers, consents, or refusals. The facility's policy emphasized encouraging vaccinations and proper documentation, but these procedures were not followed in the cases of R286 and R437.
Failure to Inform Residents of Council Meeting Rights
Penalty
Summary
The facility failed to inform residents of their right to organize and participate in resident group or council meetings, affecting all 92 residents. During a resident group meeting, several alert and oriented residents, including the newly elected president of the Resident Council, expressed that they were unaware of their right to participate in such meetings. They also indicated a lack of one-on-one meetings with staff to discuss concerns or suggestions. The residents expressed a desire to have a resident council meeting to openly share their needs and concerns. The Activity Director, V15, acknowledged attempts to organize resident group meetings in October and November 2023, which were unsuccessful due to residents' reluctance to speak in front of others. V15 also mentioned that many of the residents who refused had since moved out, and new residents had arrived. The facility lacked a policy regarding resident council meetings, and there was no documentation of such meetings being held in the past six months. The facility only provided records of one-on-one meetings with some residents who had already been discharged.
Delayed Call Light Response and Unresolved Grievances
Penalty
Summary
The facility failed to resolve residents' concerns regarding delayed responses to call lights, affecting three residents. Resident R5, who was cognitively intact and required maximum assistance with activities of daily living (ADLs), reported that staff often took more than 30 minutes to respond to his call light. The facility's alarm response report confirmed multiple instances where response times exceeded 30 minutes, with some delays reaching up to 73 minutes. R5's condition, including frequent incontinence, necessitated timely assistance, which was not consistently provided. Resident R4, who was moderately impaired cognitively and required maximum assistance with upper body dressing, bed mobility, and transfer, also reported long wait times for call light responses. The alarm response report for R4 showed several instances of delayed responses, with times ranging from 19 to 53 minutes. R4's incontinence and need for assistance with lower body dressing and toileting hygiene further underscored the importance of prompt staff response, which was not met. Resident R2, who was moderately impaired cognitively and required total assistance with most ADLs, including bed mobility and toileting hygiene, expressed similar concerns about delayed call light responses. The alarm response report indicated response times ranging from 15 to 38 minutes. Despite the residents' grievances being raised during resident council meetings, there was no documentation of investigations or actions taken to address these concerns. The Director of Nursing and the Administrator acknowledged the lack of documentation and investigation into the grievances, and the facility did not have a policy regarding call light response times, although staff were expected to respond within 15 minutes.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R2) who was unable to perform activities of daily living due to limited mobility and functional quadriplegia. R2's care plan required peri care with each incontinent episode. However, on the day of the survey, R2 was found with a significant amount of stool and urine on his body and bedding, indicating that he had not been checked or cleaned for an extended period. The CNA assigned to R2 admitted to checking residents every 2 to 3 hours, despite acknowledging that R2 needed more frequent checks due to heavy voiding and stooling. The wound nurse confirmed that prolonged exposure to urine and stool could lead to skin breakdown and emphasized the importance of providing peri care every two hours or sooner if necessary. The facility administrator acknowledged that there had been multiple complaints from residents about not being assisted every two hours, with some reports indicating delays of up to four hours. The facility's policy on incontinence care, dated June 2023, mandates that residents who are incontinent should be kept clean, dry, and comfortable while maintaining their dignity, which was not adhered to in this case.
Failure to Provide Adequate Skin Assessments
Penalty
Summary
The facility failed to provide appropriate skin assessments for three residents, leading to deficiencies in care. Resident 1, who had multiple diagnoses including cellulitis and diabetes, was admitted with existing wounds that were not assessed by the admitting nurse. The first documented skin observation was done by the wound nurse two days after admission, despite the care plan requiring immediate evaluation. Family members reported that the wounds were often soiled with urine, indicating a lack of proper care and monitoring. Resident 3, with diagnoses including type 2 diabetes and functional quadriplegia, had a physician's order for daily head-to-toe evaluations, which were not performed. The resident reported a sore on her buttocks, which was confirmed by a surveyor during an incontinence care observation. The CNA responsible for the resident's care had not noticed the sore prior to the surveyor's observation, indicating a lapse in regular skin assessments. Resident 4, who was admitted to hospice care and had severe cognitive impairment, required extensive assistance for turning and repositioning. Family members and a hospice nurse reported that the resident was often left in the same position for extended periods, leading to skin redness and potential breakdown. The facility's policy required regular skin assessments and turning every two hours, but these were not consistently performed. The wound nurse and other staff confirmed that skin checks were not done as frequently as required, leading to the observed deficiencies.
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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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