Nexus At Alton
Inspection history, citations, penalties and survey trends for this long-term care facility in Alton, Illinois.
- Location
- 3523 Wickenhauser, Alton, Illinois 62002
- CMS Provider Number
- 145427
- Inspections on file
- 50
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Nexus At Alton during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain an adequate supply of towels and washcloths on multiple halls and in linen rooms, with carts often empty or nearly empty and the laundry lacking clean linens ready for use. Staff reported that the facility frequently ran out of towels and washcloths, particularly when only one washer was available, and that they were always short on these items. Cognitively intact residents with complex medical conditions, including CHF, COPD, neuromuscular bladder dysfunction, spinal muscular atrophy, cerebral infarction, DM, HTN, and MDD, reported not receiving regular showers or bed baths and, in one case, having to use a pillowcase to dry off due to the lack of towels. The facility assessment stated that necessary bed and bath linens would be provided for routine care and emergencies, but observations and interviews showed this was not occurring.
Surveyors found that medications scheduled for morning administration were given several hours late and one ordered medication was omitted for three cognitively intact residents with complex medical and psychiatric conditions. An RN, working with fewer nurses than usual, combined morning and later medication passes and appeared flustered while administering multiple cardiac, psychotropic, respiratory, diabetic, and seizure medications well past their scheduled times. Residents reported that medications were sometimes late or missed, and the facility’s own policy required medications to be administered at the proper time and dose, with documentation and provider notification when orders could not be followed.
The facility failed to ensure food was appetizing and maintained at safe, palatable temperatures for two residents, one with dementia and weakness on a regular diet and another with diabetes, prior cerebral infarction, and COPD on a carbohydrate-controlled diet. Both residents, who were cognitively intact and used wheelchairs, complained that the food was terrible and always cold. Meal observation showed chicken at 118°F and broccoli casserole at 114°F, below the facility’s policy requirement to hold food at 135°F or greater. A cook acknowledged food should be around 170°F, the dietary manager attributed low readings to end-of-service timing, and two LPNs reported that nurse aides routinely rewarm residents’ food in the microwave.
Several cognitively intact residents with complex medical needs were unable to access hot water for bathing over multiple days due to malfunctioning water heaters. During this period, residents were given cold showers, wet wipe baths, or had to refuse bathing, with no consistent alternatives provided. Staff and maintenance confirmed the ongoing hot water supply issues, which impacted residents' ability to receive safe and comfortable care.
Several cognitively intact residents with complex medical needs were unable to access hot water for bathing over multiple days due to malfunctioning water heaters. During this period, residents were either given cold showers, wet wipe baths, or had to refuse bathing, with no consistent alternative provided. Staff and maintenance confirmed the hot water shortage and equipment failure, which impacted the facility's ability to meet residents' basic needs.
Two residents did not receive their prescribed oxycodone for pain management due to lapses in medication reordering, pharmacy delivery, and prescription renewal. Both residents, who were cognitively intact, experienced missed doses, with one resident missing six doses and reporting significant pain. Staff interviews and documentation confirmed that medication shortages sometimes occurred, particularly during pharmacy changes or when new orders were needed, and that facility policy for handling such situations was not consistently followed.
Five residents with various medical conditions did not receive their physician-ordered health shakes or dietary supplements during meal service. Although the dietary manager prepared the supplements, staff delivering trays failed to check meal tickets and ensure the correct items were provided, leading to the omission of required supplements for residents needing assistance or supervision with eating.
A resident with chronic respiratory failure and tracheostomy status, who relies on staff for daily care, was found with a soiled pillowcase and stained towel that were not changed over multiple days. Facility staff confirmed that dirty linens should be replaced, but the linens remained unchanged during the survey period.
Two residents did not receive complete incontinent care, as staff failed to cleanse all necessary areas and did not use proper technique, such as using new towels for each area and ensuring the skin was dried before applying a new brief. These actions did not follow facility policy for perineal care and hygiene.
A resident with a tracheostomy and chronic respiratory failure was found with soiled trach ties and collar, drainage, and a rash, while performing his own trach care using improper technique. An LPN assisting did not follow sterile procedures or proper hand hygiene, and the DON was unaware the resident was self-performing care without appropriate education or monitoring, contrary to facility policy.
A resident with a tracheostomy and chronic respiratory failure received care from an LPN who did not wear a protective gown, failed to perform hand hygiene when changing gloves, and did not clean multi-use equipment after use. The LPN also touched her hair with gloved hands and did not encourage or assist the resident with hand hygiene, contrary to facility infection control policies.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Three residents did not consistently receive wound treatments as ordered, with multiple days lacking documentation of dressing changes on their TARs. Residents with conditions such as diabetes, obesity, and cellulitis reported missed or inconsistent wound care, and staff confirmed that treatments should be documented immediately after completion according to facility policy.
A resident with a history of blindness in one eye, low vision in the other, and a diagnosis of cataract did not receive a timely ophthalmology appointment despite multiple physician orders and urgent referrals. Staff cited insurance issues and difficulty finding a provider, and documentation showed a lack of consistent follow-up, resulting in the resident's worsening vision and continued impairment.
Several residents with no cognitive deficits reported that staff did not answer call lights in a timely manner, resulting in prolonged waits for assistance, including one instance where a resident remained on a bedpan for an hour and another left unattended in the shower. The ADON stated call lights should be answered within two minutes, in accordance with facility policy.
The facility did not follow its fall prevention policy for three high-risk residents, failing to complete root cause analyses, update care plans, or implement new interventions after each fall. Incident reports were incomplete, and required fall prevention measures were not consistently in place or documented. Staff interviews confirmed that these deficiencies occurred, and activity assessments were not completed as required.
Two residents with a history of incarceration together, both identified as offenders, were involved in repeated incidents where one resident bullied, threatened, and sexually abused another. The victim, who had multiple medical and psychiatric diagnoses, became fearful, isolated, and refused therapy after the abuse. Staff and other residents observed ongoing intimidation, but care plans and facility actions failed to address the bullying or provide adequate protection.
Four residents with severe cognitive and medical conditions did not receive the physician-ordered diets, such as pureed or mechanical soft diets, and instead were served regular meals identical to other residents. Staff were unaware of dietary orders, meal tickets were missing or outdated, and the dietary manager acknowledged the special diet list was not current. Residents and staff confirmed that individualized dietary needs were not met, contrary to facility policy.
Two residents with a history of incarceration together were involved in allegations of sexual assault and ongoing bullying, which were not thoroughly investigated or consistently documented by the facility. Staff and another resident reported knowledge of bullying and threats, but the facility failed to follow its abuse prevention policy, did not report the allegations to the state agency, and conducted an inconsistent investigation, resulting in a deficiency.
A resident with multiple complex medical conditions was admitted with specific hospital discharge medication orders, but these were not transcribed or administered for several days due to failures in the admission process and lack of oversight. The resident did not receive critical medications, resulting in significant adverse effects, including an untreated UTI and hospitalization. Staff interviews confirmed that the required triple check system was not completed and that agency nurses did not ensure timely medication administration.
A resident with multiple chronic conditions was admitted and did not receive several critical medications, including antibiotics, antihypertensives, and diabetes treatments, due to the facility's failure to transcribe hospital discharge orders and obtain medications from the pharmacy. The resident experienced symptoms such as shortness of breath and heart palpitations, and was ultimately hospitalized for untreated infection and other complications. Staff interviews and documentation revealed that the admission process was not completed as required, and established procedures were not followed.
A resident with multiple complex medical conditions did not receive several critical medications after admission due to a failure to timely transcribe hospital discharge orders and complete required medication administration processes. Agency nurses did not complete the transcription or triple check procedures, resulting in missed doses of antibiotics and other essential medications. The resident subsequently experienced shortness of breath, heart palpitations, and an untreated UTI, leading to hospitalization.
A resident with multiple complex medical conditions was admitted and did not receive prescribed medications as ordered by the physician because the admitting nurse failed to transcribe hospital discharge orders to the POS and MAR in a timely manner. The orders were not entered or sent to the pharmacy for several days, and the facility's required triple check system for new admissions was not completed, resulting in a lapse in medication administration.
Multiple incidents occurred in which residents were subjected to physical and sexual abuse by other residents, including inappropriate touching in a dining area, physical altercations involving hitting and object throwing, and insufficient supervision in common areas. Staff and dietary aides often witnessed these events, but were not always able to intervene promptly, and documentation was sometimes incomplete for the residents involved.
A resident with severe cognitive impairment and dependence on dialysis missed multiple dialysis sessions and exhibited a significant change in condition. Facility staff failed to send the resident for evaluation and treatment after repeated refusals, despite policy requiring action after a pattern of treatment refusals. Communication breakdowns among nursing, dialysis staff, and the nephrologist led to a delay in hospital transfer, resulting in the resident's acute deterioration and ICU admission.
A resident with chronic pain and multiple medical conditions did not receive several scheduled doses of prescribed Oxycodone because the medication was out of stock and unavailable in the dispensing machine. Nursing staff confirmed the shortage and the resident reported increased pain and frustration, resulting in him staying in bed and being unable to participate in daily activities.
A resident with chronic pain and multiple medical conditions did not receive several scheduled doses of prescribed Oxycodone because the medication was not available in the facility. The resident experienced significant pain, was unable to participate in daily activities, and expressed frustration. Staff confirmed the medication was out of stock and awaiting pharmacy delivery, and the contingency supply was also depleted.
Several residents with medical needs, including diabetes and renal disease, were not consistently offered nighttime snacks as required. Some reported never receiving snacks at night, while others noted that available snacks were quickly taken by a few individuals, leaving none for the rest. Staff confirmed that snacks were only provided upon request, and meeting minutes reflected ongoing concerns about snack availability after dietary staff hours.
A resident with severe cognitive impairment was prescribed Tramadol for pain and discharged from therapy after repeated refusals, but the Power of Attorney was not notified or asked for consent regarding these significant changes. Staff interviews and record review confirmed the lack of documentation and communication, despite facility policy requiring notification of responsible parties in such situations.
The facility did not provide a final written report of an abuse investigation after an altercation between two residents, despite initial reporting and assessments showing no injuries. The required final report documenting the investigation's results and any corrective actions was not completed or submitted to the Department of Public Health, as mandated by facility policy.
Two residents were involved in an alleged altercation in the dining room, with reports of coffee being thrown and possible physical contact. Although assessments showed no injuries and both residents denied the incident, a dietary staff member reported witnessing physical aggression and intervened. The incident was reported to administration, but there was no evidence that a full investigation was conducted as required by the facility's abuse policy.
A resident, who was cognitively intact and had certain medical conditions, experienced verbal abuse from a dietary staff member during breakfast. The staff member used inappropriate language in response to a conversation about the facility's food. The incident was confirmed by another staff member and documented in the facility's report. Despite the facility's policy against abuse, this incident occurred, highlighting a failure to prevent verbal abuse.
A cognitively intact resident reported being inappropriately touched by another resident, but the facility failed to conduct a thorough investigation or report the incident to authorities. Despite the presence of witnesses and available camera footage, the facility did not adhere to its abuse policy, resulting in a deficiency.
The facility failed to follow its Abuse Prevention policy for a resident involved in alleged sexual abuse incidents. Despite being informed of incidents, no investigations were conducted, and they were not reported to an outside agency. The facility's cameras were not reviewed, and the incidents were not reported as required by the facility's policy.
A facility failed to measure, assess, monitor, and treat wounds for a resident with osteomyelitis and diabetes. The resident's left elbow wound was not treated until days after admission, and a right toe wound was not documented or treated promptly. Staff interviews revealed uncertainty in wound assessment procedures, and the facility's policy on wound management was not followed, leading to inadequate documentation and treatment of the resident's wounds.
Two residents in a facility received inadequate care for pressure ulcers due to improper assessment, monitoring, and treatment. One resident had a dressing that was not changed timely, leading to bleeding and drainage, while another received incorrect treatment due to a discrepancy in physician orders. The facility's failure to follow its own wound care policies resulted in these deficiencies.
A facility failed to replace a loose PICC line dressing for a resident with osteomyelitis and diabetes mellitus. An RN observed the loose dressing but did not change it immediately, instead informing the night RN to do so. The facility's policy required dressings to be changed if they were loose, but this was not followed.
A resident's POA repeatedly requested access to medical records without success, despite the facility's policy requiring records to be accessible within 24 hours. The resident, with a complex medical history, had been waiting since early 2024 for the records, with no documentation of the request being fulfilled. Interviews revealed a lack of communication and follow-through by the facility staff.
A resident with multiple medical conditions was discharged from the facility without proper coordination, resulting in a lack of medication provision. The care plan indicated a need for long-term care, but the discharge was not documented or planned accordingly. The family was not informed about the discharge timing, leading to confusion and distress over the lack of medication, which was not documented as sent with the resident.
A resident, who is cognitively intact and frequently incontinent, was not provided with appropriate toileting assistance, compromising his dignity. Despite being independent with toileting before, his care plan did not address his needs, and his wheelchair could not fit through the bathroom door. Staff did not assist him with using a bedside commode, urinal, or bedpan, leading to feelings of helplessness and embarrassment. Facility policies on maintaining dignity and providing adaptive equipment were not followed.
The facility failed to obtain informed consent for psychotropic medications for two cognitively intact residents. One resident received Zoloft without consent, and another was prescribed Trazodone and Duloxetine without being informed or consenting. The facility's policy requires informed consent and documentation, which was not followed.
A resident with a tracheostomy did not receive consistent care as outlined in their care plan, leading to respiratory issues and hospitalization. The resident reported irregular trach care and staff reluctance to perform necessary procedures. Facility documentation and staff interviews confirmed lapses in care, contributing to the resident's health decline.
A resident with ESRD missed a critical vascular clinic appointment due to the facility's failure to arrange transportation, leading to ineffective dialysis procedures. The resident's dialysis access points were compromised, and the facility's lack of communication and coordination resulted in the resident being sent to the ER without receiving necessary intervention.
The facility failed to provide appropriate food portions to residents, leading to dissatisfaction and potential nutritional issues. Observations and interviews revealed that residents received smaller portions than specified on the menu, and the cook confirmed inconsistencies in portion sizes due to a lack of measurement tools. The facility lacked a policy for serving appropriate portion sizes, resulting in varied meal servings.
The facility failed to obtain and properly document code status for five residents, leading to discrepancies in their electronic health records and POLST forms. The issue was acknowledged by the DON and Administrator, who stated that code status should be addressed promptly after admission.
The facility failed to ensure palatable and appetizing meals for five residents, with reports of cold and unappetizing food. Test tray temperatures were below the facility's policy requirements, indicating non-compliance with food service policies.
The Facility failed to follow their alternative menu for six residents, who reported dissatisfaction with the limited food alternatives provided, specifically noting that grilled cheese was often the only option available. Despite the Facility's policy to offer alternative selections of comparable nutritional value, staff interviews and resident feedback indicated that the Facility did not adhere to its own policies.
The facility failed to maintain proper infection control practices during dialysis treatment for seven residents. Staff members were observed not wearing appropriate PPE, improperly storing syringes, and failing to use sterile gauze and tape for dialysis sites. Additionally, inadequate hand hygiene and cleaning practices were noted.
The facility failed to transcribe and carry out a physician's order for a specialist appointment for a resident with multiple serious diagnoses, including cirrhosis of the liver and thrombocytopenia. The appointment was not scheduled, despite critical lab results indicating low white blood cell and platelet counts. The facility's policy did not cover the making of initial appointments, leading to a lapse in care.
The facility failed to provide timely access to medical records for two residents. Despite multiple requests and follow-ups by the residents' representatives, the facility's staff and corporate office did not coordinate effectively, resulting in significant delays and lack of communication. The facility's policy lacked a specified time frame for processing such requests, contributing to the issue.
Failure to Maintain Adequate Supply of Towels and Washcloths for Resident Care
Penalty
Summary
The facility failed to provide an adequate supply of towels and washcloths, resulting in residents not receiving safe, clean, and comfortable care and bathing. Surveyors repeatedly observed linen carts and clean linen rooms on multiple halls with few or no towels and washcloths over two consecutive days. On one day, three of four hall linen carts had no towels or washcloths and the fourth had only one towel; the clean linen room for two halls contained only three towels and eight washcloths. The following day, several carts and linen rooms still had minimal or no towels and washcloths, and the laundry room had no clean towels or washcloths ready for distribution, with the laundry aide folding only a few items. A CNA reported that the facility runs out of towels and washcloths, especially when only one washer is available, and the laundry aide stated they are always short on these items and was unsure if linens had been ordered recently. Cognitively intact residents reported that the lack of linens directly affected their bathing and hygiene. One resident with encephalopathy, a right below-knee amputation, chronic systolic CHF, and HTN stated the facility ran out of towels and washcloths and she had to use a pillowcase to dry off after bathing. Another resident with COPD, abnormal posture, depression, neuromuscular bladder dysfunction, and weakness stated she had not received a shower since the previous week because staff told her there were no towels or washcloths. A third resident with neuromuscular bladder dysfunction, Arnold Chiari syndrome, spinal muscular atrophy, and congenital spinal cord malformations stated showers were offered only "once in a blue moon" and that the facility never had towels and washcloths for showers or bed baths. A fourth resident with cerebral infarction, COPD, type 2 DM, HTN, hyperlipidemia, seizures, MDD, and chronic bilateral lower extremity embolism and thrombosis stated there were never enough towels and washcloths. The administrator acknowledged awareness of linen supply issues and referenced prior lapses in ordering under previous administration, while the facility assessment documented that the facility would provide necessary bed and bath linens for day-to-day operations and emergencies.
Late and Omitted Medication Administration Due to Inadequate Nurse Staffing
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within the specified time frames and as ordered for three residents during a medication pass. On 2/19/26, an RN was observed administering multiple morning medications scheduled for 9:00 AM to three residents between 11:36 AM and 12:04 PM. For one resident, loratadine, nicotine patch, metformin, atorvastatin, buspirone, famotidine, hydrochlorothiazide, lisinopril, Seroquel, and a mometasone furoate inhaler, all ordered for 9:00 AM, were not administered until 11:36 AM. This resident had diagnoses including paranoid schizophrenia, hyperlipidemia, hallucinations, mild intellectual disabilities, depression, shortness of breath, and weakness, and the care plan included interventions to administer statin, psychotropic, and respiratory medications as ordered. A second resident’s medications, including Anora Ellipta inhaler, atorvastatin, cetirizine, cholecalciferol, lisinopril, a multivitamin with minerals, levetiracetam, and metformin, all ordered for 9:00 AM, were not administered until 11:44 AM. This resident, who was cognitively intact, reported that nurses were sometimes late with medications. The resident’s diagnoses included cerebral infarction, COPD, type 2 DM, HTN, hyperlipidemia, seizures, MDD, and chronic bilateral lower extremity embolism and thrombosis, and the care plan documented risks related to diabetes, hypertension, statin use, psychotropic use, COPD, and seizure activity, with interventions to administer medications as ordered. For a third resident, iron sulfate, divalproex, duloxetine, cyanocobalamin, metoprolol, Abilify, furosemide, potassium chloride, Entresto, and hydroxyzine, ordered for 9:00 AM (with Entresto ordered at 7:00 AM and 7:00 PM), were not administered until 12:04 PM, and dapagliflozin ordered for 9:00 AM was not available and therefore not given. This resident had multiple diagnoses including multiple sclerosis, pulmonary nodule, polyosteoarthritis, anemia, thyrotoxicosis, muscle spasm, hyperlipidemia, PTSD, congestive heart failure, low back pain, hypokalemia, vitamin deficiency, anxiety disorder, and bipolar disorder, with a care plan calling for administration of statin and psychotropic medications as ordered. The RN administering medications appeared flustered and stated that only three nurses were working instead of the usual four, causing her to run behind and combine morning and 11:00 AM medications, and stated that having only three nurses was affecting the quality of care. The facility’s medication administration policy required medications to be given at the proper time and dose, with documentation and provider notification if medications were not given as ordered or not present.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide appetizing food at palatable and safe temperatures for residents receiving food and nutrition services. One resident with dementia and weakness, who was cognitively intact, used a wheelchair, and was on a regular therapeutic diet, reported that the food was horrible and always cold. Another cognitively intact resident with diabetes mellitus, cerebral infarction, and COPD, who also used a wheelchair and was on a carbohydrate-controlled diet, stated that some of the food was terrible and that they would not even give that food to a dog. During observation of a meal service, food temperatures were taken with a calibrated metal thermometer after the last resident tray was served. The chicken measured 118°F and the broccoli casserole measured 114°F, while the cook stated the temperature should be around 170°F. The dietary manager later stated that the temperatures may have been lower because they were taken at the end of service. Two LPNs reported that the food is always cold and that nurse aides always have to rewarm residents’ food in the microwave. The administrator stated she expects dietary staff to follow the facility’s undated Food Temperatures Policy, which requires food to be held at 135°F or greater throughout the service process.
Failure to Provide Consistent Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide consistent access to hot water for bathing for four cognitively intact residents, each with significant medical conditions such as fractures, diabetes, cerebral infarction, multiple sclerosis, and malnutrition. Over a period earlier in the month, these residents experienced a lack of hot water for several days, with some reporting up to two weeks without hot water. During this time, residents were either given cold showers, wet wipe baths, or had to refuse bathing altogether, with no alternative options consistently offered. Staff interviews and documentation confirmed that the facility experienced ongoing issues with its hot water supply due to malfunctioning water heaters, which were unable to meet the demand. Maintenance staff and administration acknowledged the problem, noting that one of the two hot water tanks was out of order and that the facility had a history of running out of hot water under normal conditions. The lack of hot water affected both the men's shower room and general bathing routines, resulting in residents not receiving safe and comfortable bathing as required by resident rights policies.
Failure to Provide Consistent Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide consistent access to hot water for bathing for four cognitively intact residents, each with significant medical conditions such as fractures, diabetes, cerebral infarction, multiple sclerosis, and malnutrition. Over a period earlier in the month, these residents reported having no hot water for several days, with some stating the issue lasted up to two weeks. During this time, residents were either forced to take cold showers, refuse showers, or were only offered wet wipe baths as an alternative. Documentation and interviews confirm that staff were aware of the lack of hot water, and that the issue affected both the men's shower room and the general hot water supply after a water tank failure. Staff interviews and facility records indicate that the hot water shortage was due to malfunctioning water heaters, with one tank completely out of order and the facility unable to meet hot water demand under normal conditions. The maintenance director and regional maintenance director confirmed the problem, noting that the facility ran out of hot water after a few showers and that professional services were required to replace the faulty equipment. During the outage, there was no consistent alternative provided to residents for bathing, and the facility's own policy requires a safe, comfortable, and homelike environment, which includes access to hot water.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide physician-prescribed pain medication to two residents, resulting in missed doses and unmanaged pain. One resident, who was cognitively intact and suffered from phantom limb pain and a wound infection, missed six doses of oxycodone over a three-day period. The resident reported significant pain during this time, stating that the medication had run out and expressing uncertainty about whether the issue was due to a failure to reorder or a delay in pharmacy delivery. Documentation confirmed the missed doses, and staff interviews indicated that the prescription had expired and there was a possible change in providers. Another cognitively intact resident also missed three doses of prescribed oxycodone. Nursing notes revealed that the pharmacy had only partially filled the order, and a new prescription from the physician was required. Staff interviews acknowledged that running out of pain medication sometimes occurred, especially during pharmacy transitions or when new prescriptions were needed. The facility's policy required staff to check for misplaced medications, contact the pharmacy, use contingency supplies if available, and notify the physician if orders could not be followed, but these steps were not effectively implemented, resulting in the residents not receiving their prescribed pain management.
Failure to Provide Physician-Ordered Dietary Supplements During Meal Service
Penalty
Summary
The facility failed to provide physician-prescribed health shakes to five residents during meal service. On observation, none of the five residents received their ordered dietary supplements with their meals, despite having physician orders specifying the need for health shakes or supplements such as diabetic shakes or Med Pass 2.0. Interviews revealed that the dietary manager had prepared the shakes and placed them on the cart, but the aides delivering the trays did not check the meal tickets to ensure the correct supplements were provided. One resident reported that the shakes are often forgotten. The affected residents had various diagnoses, including aphasia, cerebrovascular disease, diabetes, dementia, schizoaffective disorder, hemiplegia, and alcohol-induced disorder. Their cognitive and physical abilities ranged from severely impaired to cognitively intact, with most requiring some level of assistance or supervision with eating. Facility policy required staff to verify that the correct tray and diet matched the resident's needs at delivery, but this procedure was not followed, resulting in the omission of prescribed dietary supplements.
Failure to Provide Clean Linens for a Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with chronic respiratory failure, hypoxia, and tracheostomy status, was observed to have soiled linens that were not changed over multiple days. The resident, who is cognitively intact and dependent on staff for activities of daily living and mobility, was found lying in bed with a pillowcase that had a large brown stain on two consecutive days. Additionally, a white towel with dried green and brown stains was observed on the resident's bed rail. Interviews with facility staff, including the DON and Administrator, confirmed that linens should be changed when dirty, but the soiled linens remained in place during the observations.
Incomplete Incontinent Care and Perineal Hygiene
Penalty
Summary
Staff failed to provide complete incontinent care for two residents who were always incontinent of bowel and bladder. For one resident with severe cognitive impairment and total dependence on staff for toileting, a CNA missed cleansing the left buttock during perineal care after removing a soiled brief containing urine and feces. The CNA acknowledged missing this area due to nervousness. For another resident, who was cognitively intact but required supervision and assistance with toileting, a CNA used the same portion of a washcloth to cleanse multiple areas, did not cleanse the right buttock, and did not dry the resident before applying a new brief after removing a urine-soiled brief. The facility's policy requires complete cleansing of the perineal area with appropriate cleansers, use of multiple towels for cleaning, rinsing, and drying, and cleansing from front to back. The Director of Nurses confirmed that staff should be performing complete incontinent care, including using new towels for each area and ensuring residents are dried before a new brief is applied. These requirements were not followed during the observed care for both residents.
Failure to Provide Complete and Sterile Tracheostomy Care
Penalty
Summary
The facility failed to provide complete and appropriate tracheostomy care for a resident with chronic respiratory failure and a tracheostomy. The resident was observed with wet, soiled tracheostomy ties and collar, yellow, green, and brown drainage, and a foul odor, as well as a red spotted rash on the neck and upper chest. There was no drainage sponge under the tracheostomy, and the resident was seen cleaning the area himself using the same gauze pad multiple times, without being offered hand hygiene. The LPN assisting the resident did not consistently perform hand hygiene between glove changes, touched her hair with gloved hands, and did not follow sterile technique as outlined in the facility's tracheostomy care policy. The resident, who is cognitively intact but dependent on staff for activities of daily living, reported that he has been caring for his tracheostomy for several years and prefers to do it himself, although staff will assist if asked. The DON was unaware that the resident was performing his own tracheostomy care and acknowledged that the resident should have been educated and monitored to ensure proper technique. The facility's policy requires daily cleaning of the inner cannula, changing of tracheostomy ties and collar when soiled, and strict adherence to sterile procedures, which were not followed in this instance.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection prevention and control protocols while providing tracheostomy care to a resident with chronic respiratory failure, hypoxia, and a tracheostomy. The LPN did not wear a personal protective gown as required for Enhanced Barrier Precautions, did not consistently perform hand hygiene when changing gloves, and failed to provide a sterile field for supplies. During the care, the LPN touched her hair with gloved hands, reused gloves without hand hygiene, and did not encourage or assist the resident with hand hygiene before, during, or after the procedure. Additionally, the LPN did not clean multi-use equipment, such as a pulse oximeter, after use on the resident. The resident, who was colonized for wounds, had visible drainage on the tracheostomy collar and neck. The LPN and the resident both handled supplies and performed parts of the care without appropriate infection control measures, including the reuse of gauze pads and lack of hand hygiene. Facility policies required the use of gowns and gloves for high-contact care, hand hygiene before and after resident contact, and cleaning of equipment between residents, but these protocols were not followed during the observed care.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Perform and Document Wound Treatments as Ordered
Penalty
Summary
The facility failed to perform wound treatments as ordered for three residents, as evidenced by interviews and record reviews. One resident reported not always receiving dressing changes to his left knee as prescribed, with treatment administration records (TARs) showing multiple days in May and June without documentation of the required wound care. This resident had a history of left knee pain, morbid obesity, and a left artificial knee joint, and was assessed as cognitively intact but requiring assistance with mobility and hygiene. Another resident stated that dressing changes to his left middle finger were not performed daily as ordered, with TARs indicating several days in June and July without documentation of the treatment. This resident had diagnoses of type 2 diabetes and hypertension and was at risk for skin complications due to a cerebrovascular accident and malnutrition. A third resident reported that staff did not change the dressing on his left lower leg daily, sometimes going multiple days without a change. Review of TARs for this resident, who had cellulitis and congestive heart failure, showed several days in June and July without documentation of the required dressing changes. Facility staff, including the DON and wound nurse, confirmed that dressing changes are to be documented on the TAR as soon as they are completed, and that lack of documentation would indicate the treatment was not performed. The facility's policy requires consistent implementation of wound monitoring and documentation protocols.
Failure to Arrange Ophthalmology Appointment for Resident with Severe Vision Impairment
Penalty
Summary
The facility failed to arrange a specialty physician appointment for a resident with a history of blindness in one eye, low vision in the other, and a diagnosis of cortical age-related cataract in the right eye. Despite multiple physician orders and care plan interventions indicating the need for ophthalmology evaluation and treatment for cataracts and worsening vision, the resident did not receive an appointment with an eye doctor for an extended period. Documentation showed repeated referrals and urgent requests for ophthalmology consultation, but the resident reported never having seen an eye doctor since admission. Staff interviews confirmed the resident's ongoing vision impairment and the lack of successful appointment scheduling due to insurance issues and difficulty finding a provider who accepted the resident's insurance and treated cataracts. Observations revealed the resident ambulating with a slow gait, using hands to navigate due to severely impaired vision. The resident expressed that his vision had worsened during his stay and described pain in his right eye. The facility's transportation staff kept only handwritten notes to track appointment attempts, and there was no documented evidence of consistent follow-up or outreach to ophthalmologists. The facility's policy required physician orders to be followed as written, but there was no proof that the necessary steps were taken to ensure the resident received timely ophthalmology care.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for six residents who were reviewed for call light response. Multiple residents, all documented as having no cognitive deficits per their Minimum Data Set (MDS), reported that staff did not respond promptly to their call lights. One resident stated they had to wait on a bedpan for an hour due to unanswered call lights, while another reported being left unattended in the shower. Additional residents confirmed during a resident council meeting that staff routinely ignored call lights, with one resident noting that they had to call out for their roommate because staff did not respond. The Assistant Director of Nursing stated that the expectation is for call lights to be answered within two minutes. The facility's call light policy, revised in September 2022, provides guidance for staff on responding to residents' requests and needs.
Failure to Follow Fall Prevention Policy and Update Care Plans After Falls
Penalty
Summary
The facility failed to follow its Fall Prevention and Management policy for three residents identified as high risk for falls. For one resident with severe cognitive impairment and multiple comorbidities, the care plan was not updated after a fall, and no new interventions were documented to reduce future fall risk. The fall was not recorded in the electronic medical record, and there was no documentation of post-fall monitoring or follow-up, despite the resident being sent to the emergency department for evaluation. The Director of Nursing confirmed that required documentation and monitoring were not completed as per facility policy. Another resident with moderate cognitive impairment and a history of repeated falls experienced multiple falls, but incident reports lacked root cause analyses and did not document new interventions to prevent further incidents. Required sections of the incident reports, such as environmental and physiological factors, were left blank. Observations revealed that prescribed fall prevention interventions, such as side rails and floor mats, were not in place at the time of surveyor inspection, and the care plan was not updated after each fall as required. A third resident, also severely cognitively impaired and dependent for all activities of daily living, experienced several falls. Incident reports for these events did not include root cause analyses or documentation of new interventions. The care plan was not updated following these incidents, and the activity director was unaware of the resident's fall interventions and had not completed an activity assessment since admission. The facility's policy requires a root cause analysis and care plan update with new interventions after each fall, but these steps were not followed for the residents reviewed.
Failure to Prevent Resident-on-Resident Abuse and Bullying
Penalty
Summary
The facility failed to protect two residents from abuse and the assertion of dominance by another resident, despite both individuals being identified offenders with a known history of prior incarceration together. One resident, who had diagnoses including cerebral infarction, cerebral palsy, epilepsy, schizophrenia, and major depressive disorder, reported being sexually assaulted in his room by another resident. The victim described being physically overpowered and sexually abused, recognizing the perpetrator by voice and sight. Multiple interviews with the victim, other residents, and staff confirmed ongoing bullying, threats, and physical intimidation by the alleged perpetrator, both in the facility and previously in prison. The care plans for the victim documented risks for abuse and prior allegations of sexual assault, but did not address the ongoing bullying or dominance by the other resident. There was no evidence of behavior tracking for the victim, and the care plan lacked interventions specific to the bullying and dominance issues. Staff and other residents reported witnessing the perpetrator's aggressive and intimidating behavior, including physical threats and harassment during smoke breaks and in common areas. Staff also reported that previous concerns about the perpetrator's behavior had been dismissed by prior administration. The facility's policies required the identification and care planning for residents at risk of abuse, as well as the incorporation of security measures for identified offenders. However, the care plans and progress notes for the perpetrator did not document the abuse allegations or the need for enhanced supervision. The facility failed to implement adequate measures to prevent further abuse, intimidation, and psychological harm, resulting in the victim becoming fearful, socially withdrawn, and refusing therapy and medical evaluation due to fear and embarrassment.
Failure to Provide Physician-Ordered Diets to Residents
Penalty
Summary
The facility failed to provide physician-ordered diets to four residents with significant medical conditions, including severe cognitive impairment, diabetes, stroke, and swallowing difficulties. Despite clear care plans and physician orders specifying specialized diets such as pureed, mechanical soft, and carbohydrate-controlled diets, these residents consistently received regular meals identical to those served to other residents. Observations revealed that meal tickets indicating dietary requirements were missing or not updated, and staff were unaware of the specific dietary needs of the residents. For example, one resident with a pureed diet order due to high aspiration risk was observed receiving and struggling to eat regular food items like toast and cereal. Staff, including CNAs and the DON, were unaware of the resident's dietary restrictions, and the dietary manager admitted the resident was not listed on the special diet roster. Other residents with orders for mechanical soft diets also received regular meals, such as noodles and beef, which were not appropriately modified according to their dietary needs. The dietary manager and cook acknowledged that the food provided did not meet the required texture modifications and that the list of residents on special diets was outdated. Interviews with residents confirmed that they routinely received the same food as everyone else, regardless of their prescribed diets. Staff interviews further revealed a lack of communication and understanding regarding residents' dietary orders. The facility's own policy required individualized diet modifications based on physician and speech-language pathologist recommendations, but these procedures were not followed, resulting in the failure to provide appropriate diets as ordered.
Failure to Thoroughly Investigate and Document Alleged Abuse and Bullying
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of abuse for two residents, both of whom were identified as offenders and had a history of incarceration together. One resident, who was cognitively intact and had multiple diagnoses including schizophrenia and cerebral palsy, reported being sexually assaulted and bullied by another resident. The care plans for both residents did not address the ongoing bullying or dominance behaviors, and there was no behavior tracking provided for the resident who reported the abuse. Multiple staff and another resident observed or were aware of the bullying and dominance behaviors, but these concerns were not consistently documented or investigated. Interviews with staff and residents revealed that the alleged perpetrator had a history of threatening and intimidating both residents and staff, including a nurse practitioner who reported being threatened. Despite these reports, the facility did not have documentation of any abuse investigations related to the bullying or the alleged sexual assault prior to the current administrator's tenure. The administrator and DON were both new to their positions and were unaware of previous allegations or investigations. The facility's abuse prevention policy required that all incidents and allegations be investigated and documented, but this was not followed in these cases. When the sexual assault allegation was finally investigated, the process was inconsistent, with residents being asked different questions and key witnesses not being asked about what they had observed. The investigation relied heavily on video surveillance, which did not substantiate the allegation, and the final report concluded the abuse was unsubstantiated. However, the lack of consistent and thorough investigation, as well as the failure to report the allegation to the state agency as required, constituted a deficiency in the facility's response to alleged violations.
Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that medications for a newly admitted resident were transcribed to the Physician Order Sheet (POS) and Medication Administration Record (MAR), obtained from the pharmacy, and administered as ordered by the physician. The resident, who had multiple complex diagnoses including chronic kidney disease, heart conditions, diabetes, and a recent urinary tract infection, was admitted with specific hospital discharge medication orders. However, these orders were not transcribed or acted upon for several days following admission. Record reviews and staff interviews revealed that the admission process was not completed in a timely manner. The admitting nurse, who was from an agency, did not transcribe the medication orders upon admission as required. The facility's triple check system, designed to ensure accurate and complete admissions, was not performed. As a result, the resident did not receive critical medications, including antibiotics, cardiac medications, and diabetes medications, for several days. Staff interviews confirmed that the medications were not available or administered, and that the issue was only discovered days later when a nurse attempted to give the resident his medications and found none available. The failure to transcribe and administer the prescribed medications led to the resident experiencing significant adverse effects, including shortness of breath, heart palpitations, and an untreated urinary tract infection. The resident reported feeling as though he was going to die. Both the facility's pharmacist and medical director confirmed that the missed medications constituted significant medication errors, with the lack of antibiotic administration resulting in hospitalization for a urinary tract infection.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
The facility failed to complete the admission process and transcribe physician-ordered medications to the Physician Order Sheet and Medication Administration Record for a newly admitted resident. As a result, the resident did not receive multiple critical medications, including antibiotics for a urinary tract infection, antihypertensives, diabetes medications, and other essential treatments for several days following admission. Documentation shows that the hospital discharge orders were not transcribed until several days after admission, and medications were not obtained from the pharmacy or administered as ordered. The resident, who had a complex medical history including chronic kidney disease, diabetes, heart disease, and a recent fracture, repeatedly reported not receiving medications and experienced symptoms such as shortness of breath, heart palpitations, and elevated blood glucose levels. Progress notes and interviews confirm that staff, including agency nurses, were aware that medications were missing and not available, and that attempts to contact the pharmacy were made but not successful in a timely manner. The facility's own policies required prompt assessment and medication reconciliation upon admission, but these steps were not completed as required. Ultimately, the resident's condition deteriorated, leading to hospitalization where it was confirmed that he had not received his prescribed medications for several days, resulting in untreated infection and other complications. Interviews with staff and review of records indicate that the failure to transcribe orders, obtain medications, and administer them as ordered was due to lapses in the admission process, lack of oversight, and failure to follow established procedures for new admissions.
Failure to Transcribe and Administer Medications Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident was admitted with multiple complex diagnoses, including chronic kidney disease, heart failure, diabetes, and a recent urinary tract infection. Upon admission, the resident's hospital discharge orders, which included several critical medications such as antibiotics, antihypertensives, anticoagulants, and diabetes medications, were not transcribed to the Physician Order Sheet (POS) or Medication Administration Record (MAR) in a timely manner. The orders were not entered until several days after admission, resulting in the resident not receiving prescribed medications for multiple days. The facility's process required the admitting nurse to transcribe orders into the electronic health record system and send them to the pharmacy, with a triple check system in place to ensure accuracy. However, the admitting nurse was from an agency, and subsequent care was also provided by agency nurses. The facility's Assistant Director of Nursing (ADON) and other staff confirmed that the transcription and triple check processes were not completed as required. The delay in transcription and medication procurement led to the resident missing essential doses of medications, including antibiotics for a urinary tract infection and medications for chronic conditions. As a result of these failures, the resident experienced significant adverse effects, including shortness of breath, heart palpitations, and an untreated urinary tract infection, which ultimately led to hospitalization. Interviews with facility staff and the medical director confirmed that the lack of timely medication administration constituted a significant medication error with serious consequences for the resident.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility and the admitting nurse failed to transcribe the hospital discharge medication orders to the Physician Order Sheet (POS) and Medication Administration Record (MAR) in a timely manner. The resident, who had multiple complex diagnoses including acute kidney injury, chronic kidney disease, hypertension, diabetes, and a history of cardiac issues, was admitted with specific medication orders from the hospital. These orders were not entered into the facility's records or sent to the pharmacy upon admission, resulting in the resident not receiving prescribed medications for several days. Record review showed that the hospital discharge orders, dated 4/2, were not transcribed to the POS and MAR until 4/5. The MAR for April documented no medication orders for the resident on 4/2, 4/3, and 4/4, and the orders only appeared on 4/5 and later dates. Interviews with facility staff, including the previous DON, interim DON, and LPNs, revealed that the admission process was handled by agency nurses, and the required triple check system for new admissions was not completed. The interim DON confirmed that medications should have been transcribed within the first few hours of admission, but this did not occur. The facility's policy requires that medication orders be documented and transcribed promptly upon admission, with orders entered into the electronic system and transmitted to the pharmacy. In this case, the process was not followed, and the resident did not receive their prescribed medications as ordered by the physician during the initial days of their stay. Staff interviews indicated a lack of clarity and follow-through in the admission process, particularly with agency nurses responsible for the resident's care.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent multiple instances of physical and sexual abuse among residents, as evidenced by several documented incidents involving both cognitively impaired and intact individuals. In one case, a severely cognitively impaired resident was inappropriately touched by another resident in the dining room, with the incident being witnessed by dietary staff. The involved residents were separated, and the event was reported to authorities, but the medical record for the alleged perpetrator did not contain any documentation related to the incident. Staff interviews confirmed that there was no staff present in the dining room at the time of the incident, and dietary staff, who are not permitted to physically intervene, were the first to respond. Additional incidents included a cognitively impaired resident striking another resident with a phone, resulting in a visible red mark, and altercations between residents involving physical aggression such as hitting and throwing objects. In one instance, a resident with dementia wandered into another resident's room and was punched in the chest. In another, two residents engaged in a physical altercation in the dining room, with one throwing coffee and the other retaliating with a punch. Documentation and staff interviews indicate that these altercations were often witnessed by non-nursing staff or occurred in areas with insufficient supervision. The records show that the residents involved had varying degrees of cognitive impairment and behavioral issues, including dementia, schizophrenia, and mood disorders. The facility's documentation and staff statements reveal that supervision was lacking at critical times, and that staff were not always able to intervene promptly to prevent or stop abusive interactions. The facility's abuse prevention policy affirms residents' rights to be free from abuse, but the events described demonstrate failures in monitoring and protecting residents from physical and sexual abuse by others.
Failure to Send Resident for Evaluation After Multiple Missed Dialysis Treatments
Penalty
Summary
A resident with severe cognitive impairment and multiple complex diagnoses, including end-stage renal disease requiring dialysis five times per week, experienced a significant change in condition after repeatedly refusing dialysis treatments. Documentation shows that the resident last received dialysis on 3/11/25 and subsequently refused all care for approximately eight days. During this period, staff noted the resident's increasing lethargy and unresponsiveness, culminating in a medical emergency that required transfer to the emergency room, where the resident was admitted to the ICU and required central venous access and vasopressor support. Interviews and record reviews revealed that the facility failed to send the resident for evaluation and treatment after multiple missed dialysis sessions. The dialysis nurse reported informing the nephrologist about the refusals and was advised to do what she could, but also stated that after three missed treatments, the standard practice was to send the resident to the hospital. The nephrologist confirmed that the resident should have been sent to the hospital after the third missed treatment, as further dialysis would not be safe without updated lab work. However, there was a breakdown in communication between the dialysis nurse, nursing staff, and facility leadership, resulting in the resident not being sent out in a timely manner. Facility policy required nursing staff to notify the physician and responsible party in the event of a significant change in condition or a pattern of refusing treatments. Despite this, the necessary notifications and actions were not consistently carried out, as some staff were unaware of the need to send the resident to the hospital after missed treatments. This lapse in following policy and communication protocols directly contributed to the resident's acute deterioration and subsequent hospitalization.
Failure to Provide Prescribed Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to provide physician-prescribed pain medication to a resident with diagnoses including Spina Bifida, Anxiety, and Bipolar Disorder, who was cognitively intact and had a documented order for Oxycodone 10 mg every four hours for osteomyelitis of the lumbar vertebra. According to the Medication Administration Record, the resident did not receive multiple scheduled doses of Oxycodone over a two-day period. Nursing staff confirmed that the medication was unavailable due to running out of stock and awaiting pharmacy delivery, and it was not accessible from the automatic medication dispensing machine. As a result of not receiving the prescribed pain medication, the resident reported significant pain, with a pain level reaching 7 out of 10, and stated he had to remain in bed all day due to abdominal pain from multiple hernias. The resident expressed frustration at not receiving his medication, which impacted his ability to participate in normal daily activities. The facility's pain management policy emphasizes the importance of providing necessary comfort and promoting resident independence and dignity, which was not achieved in this instance.
Failure to Provide Prescribed Pain Medication Due to Unavailable Supply
Penalty
Summary
The facility failed to provide a physician-prescribed pain medication, Oxycodone 10 mg, to a resident with diagnoses including Spina Bifida, Anxiety, and Bipolar Disorder. The resident, who was cognitively intact, had an active order for Oxycodone to be administered every four hours for osteomyelitis of the lumbar vertebra. According to the Medication Administration Record, the resident did not receive multiple scheduled doses of Oxycodone over a two-day period because the medication was not available in the facility. The resident reported not receiving his morning dose due to the medication running out, and staff confirmed that the pharmacy delivery was pending and the medication was not available in the automatic dispensing machine or contingency supply. As a result of not receiving the prescribed pain medication, the resident experienced significant pain, reporting a pain level of 7 out of 10, and was required to stay in bed all day, leading to frustration and inability to participate in normal daily activities. The facility's policy required staff to check for misplaced medications and contact the pharmacy or use contingency supplies if a medication was not present, but these steps did not result in the resident receiving his scheduled doses.
Failure to Consistently Offer Nighttime Snacks to Residents
Penalty
Summary
The facility failed to consistently offer nighttime snacks to four out of six residents reviewed for snack provision. Interviews and record reviews revealed that residents with significant medical conditions, such as end stage renal disease, dependence on renal dialysis, diabetes mellitus, and bipolar disorder, were not routinely offered snacks at bedtime. One resident with diabetes reported that snacks were not available, and when their blood sugar was low, staff had to purchase snacks from a vending machine using their own money. Another resident stated that snacks were sometimes available but not every night, while others reported never being offered snacks at night. The Director of Nurses stated that snacks are kept at the nurse's station and are available upon request, but this practice did not ensure that all residents were offered snacks as required. Resident Council Meeting minutes also documented concerns about the lack of snacks after dietary staff leave. The facility's own policy indicated that nursing services are responsible for delivering individual snacks to identified residents and for offering evening snacks to all other residents, which was not consistently followed.
Failure to Notify Power of Attorney of Narcotic Use and Therapy Refusal
Penalty
Summary
The facility failed to notify the legal guardian (Power of Attorney) of a resident with severe cognitive impairment regarding the initiation of a narcotic pain medication (Tramadol) and the resident's refusal and subsequent termination of therapy. The resident, who has diagnoses including Schizophrenia, Dementia, Alzheimer's Disease, and End Stage Renal Disease, was prescribed Tramadol for pain management after staff reported ongoing pain issues. Documentation shows that the resident received multiple doses of Tramadol, but there is no evidence in the medical record that the Power of Attorney was informed or gave consent for this medication, despite the resident's cognitive status and the guardian's stated concerns about the use of pain medications. Additionally, the resident began and was later discharged from both speech and physical therapy, with records indicating frequent refusals of therapy. However, there is no documentation that the Power of Attorney was notified of these refusals or the termination of therapy. Interviews with staff confirmed that notification was not documented, and attempts to contact the Power of Attorney were either not completed or not properly documented. The facility's policy requires notification of the responsible party in cases of significant changes, including new medication orders and patterns of treatment refusal, but this was not followed in this instance.
Failure to Complete and Submit Final Abuse Investigation Report
Penalty
Summary
The facility failed to provide a final abuse investigation report for two residents involved in a reported altercation. According to incident and nursing notes, an altercation occurred between two male residents in the dining room, during which coffee was thrown and there were allegations of physical contact. Both residents denied the altercation, but an eyewitness from the dietary department reported seeing one resident hit the other and intervened to separate them. Assessments were completed for both residents, with no injuries or pain reported, and both residents were monitored following the incident. The initial report of the incident was made, and the administrator was notified at the time. Despite the initial reporting and assessments, the facility did not complete or provide a final written report of the results of the abuse investigation as required by their policy. The current administrator was unable to locate a file on the incident, and only the initial report was found in an email from the DON. The facility's policy requires that a final written report, including the results of the investigation and any corrective actions, be forwarded to the Department of Public Health within five working days, but this was not done for the incident in question.
Failure to Investigate Alleged Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged altercation between two male residents, both of whom were their own responsible parties. According to incident reports and nurses' notes, a possible altercation occurred in the dining room, during which coffee was thrown and there were allegations of physical contact. Assessments were completed for both residents, and no injuries were noted. Both residents denied the altercation, but an eyewitness from the dietary department reported seeing one resident hitting the other and physically intervened to separate them. The incident was reported to the administrator, and statements were obtained from both residents, who continued to deny any physical altercation. Despite the facility's abuse policy requiring a full investigation—including interviews with all involved parties and review of relevant documentation—there was no evidence that a comprehensive investigation was conducted for this incident. The Director of Nursing stated that the initial report was made, but the current administrator could not locate a file or documentation of an investigation beyond the initial report. The only available documentation was an email from the Director of Nursing confirming the initial report, with no further evidence of follow-up or a completed investigation as required by facility policy.
Verbal Abuse Incident Involving Dietary Staff
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident, identified as R3, who was cognitively intact and had diagnoses of Polyarthritis and Chronic Obstructive Pulmonary Disease. During breakfast in the dining room, a dietary staff member, V3, verbally abused R3 by cursing at him in response to a conversation about the facility's food offerings. This incident was witnessed by another staff member, V4, who confirmed that V3 used inappropriate language towards R3. The incident was documented in the facility's Long Term Care - Serious Injury Incident and Communicable Disease Report, which confirmed the occurrence of verbal abuse. The facility's policy, dated 9/2027, affirms the residents' right to be free from abuse, including verbal abuse, which is defined as the use of disparaging and derogatory language by staff. Despite this policy, the incident occurred, indicating a failure in preventing verbal abuse. The dietary staff member involved admitted to the verbal abuse in a written statement, acknowledging that her actions were wrong. The facility's response to the incident was to immediately suspend and subsequently terminate the employee involved.
Failure to Investigate and Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of sexual abuse involving a resident, identified as R2, who was cognitively intact and had a history of sexual abuse. The incident occurred when R2 reported being inappropriately touched by another resident, R3, while waiting for a smoke break. Despite R2's clear account of the incident and the presence of witnesses, the facility did not conduct a comprehensive investigation or report the incident to the appropriate authorities as required by their abuse policy. R2's care plan indicated a risk for abuse and neglect, and the facility's policy required immediate reporting and a thorough investigation of any allegations of abuse. However, the facility's response was inadequate. The Director of Nursing and the Wound Nurse were informed of the incident, but they did not pursue further investigation or report the incident externally. The facility also failed to review available camera footage that could have provided additional evidence. The facility's Regional Director of Operations acknowledged awareness of the incident but stated that no further investigation was conducted because a staff member did not witness the event. This lack of action and failure to adhere to the facility's abuse policy resulted in a deficiency, as the facility did not ensure the safety and protection of its residents by properly addressing and reporting the allegations of abuse.
Failure to Report and Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to initiate its Abuse Prevention policy for a resident involved in an alleged sexual abuse incident. On 10/31/2024, the Regional Director of Operations, V9, stated that they were informed of an incident that occurred on 10/22/2024. Despite being notified, no further investigation was conducted, and the incident was not reported to an outside agency because the Staffing Coordinator, V6, did not witness anything. Additionally, V9 mentioned that they were later informed of another incident that occurred on 10/13/2024, which was also not reported or investigated. The facility has cameras, but the footage was not reviewed. The facility's Administrator, V2, confirmed that the incidents from 10/13 and 10/22 were not reported to an outside agency. According to the facility's Abuse Policy, any incident or allegation involving abuse should result in an investigation, and the Department of Public Health's regional office should be notified immediately. A complete written report of the investigation's conclusion should be sent within five working days. The facility's failure to follow these procedures resulted in a deficiency in handling the alleged abuse incidents.
Failure to Properly Assess and Treat Wounds
Penalty
Summary
The facility failed to properly measure, assess, monitor, and treat wounds for a resident identified as R4, who was admitted with osteomyelitis and diabetes mellitus. Upon admission, R4 had a left elbow infection and was on intravenous antibiotics. However, there was a lack of timely documentation and treatment for the wounds. The Treatment Administration Record showed no treatment for the left elbow wound before October 17, 2024, and no treatment for the right second toe wound before October 23, 2024. Additionally, the Skin and Wound Note from October 11, 2024, incorrectly documented that R4 had no open wounds, despite the presence of a left elbow wound noted upon admission. Interviews with facility staff revealed gaps in the wound assessment process. The Licensed Practical Nurse (LPN) responsible for wound care admitted uncertainty about whether wounds were measured upon admission or readmission. The Director of Nurses stated that wounds should be measured and described when found, with weekly follow-ups or if the condition worsens. The facility's policy on Skin and Wound Management Guidelines was not followed, as it required comprehensive nursing assessments, including skin integrity documentation and obtaining treatment orders for wounds present on admission. The policy also lacked documentation for ongoing wound or pressure ulcer assessment.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to properly assess and monitor pressure ulcers, provide physician-prescribed treatment, and maintain clean dressings for two residents. One resident, who was at risk for developing pressure ulcers due to conditions such as Type 2 Diabetes Mellitus and End Stage Renal Disease, was found with a dressing that had not been changed in a timely manner, leading to bleeding and drainage. The resident's right heel dressing was improperly positioned, and the left heel had no dressing at all. The facility's records showed inconsistent documentation and assessment of the resident's pressure ulcers, with significant gaps in the medical record. Another resident, who had a Stage 4 pressure ulcer on the sacrum, received incorrect treatment due to a discrepancy between the physician's orders and the treatment administered by the staff. The staff member responsible for the treatment admitted to entering the wrong order into the system, which could have led to the resident receiving the wrong treatment if another nurse had performed the dressing change. The facility's policy on skin and wound management was not followed, as there was a lack of comprehensive assessment and documentation of the resident's wounds upon admission and readmission. The facility's failure to adhere to its own policies and procedures for wound care management resulted in inadequate care for residents with pressure ulcers. The lack of consistent assessment, documentation, and adherence to physician orders contributed to the deficiencies observed by the surveyors. The facility's staff, including the Director of Nurses and the Wound Nurse Practitioner, acknowledged the shortcomings in the wound care process, but the report does not mention any corrective actions taken to address these issues.
Failure to Secure PICC Line Dressing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident with a Peripherally Inserted Central Catheter (PICC) line. During an observation, the Assistant Director of Nurses, a Registered Nurse (RN), was seen disconnecting an IV antibiotic from a resident's PICC line and flushing it with normal saline. However, the PICC line dressing was noted to be loose at the bottom, and the RN did not replace it at that time. Instead, she informed the night RN to change it later. The resident, who was admitted with osteomyelitis and diabetes mellitus, had physician orders to change the PICC line dressing weekly and as needed using sterile technique. The facility's policy required dressings to be changed every seven days or more frequently if they were soiled, damp, or loose. The Director of Nurses later stated that RNs should change a PICC line dressing immediately if it is not secure.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to uphold a resident's right to access their medical records, as evidenced by the case of a resident whose Power of Attorney (POA) repeatedly requested access to the resident's medical records without success. The resident, who has a complex medical history including sepsis, transient cerebral ischemic attack, type 2 diabetes, and Alzheimer's disease, was admitted to the facility and later transported to the emergency room. Despite the POA's multiple attempts to obtain the records since February 2024, including filling out necessary forms and meeting with facility staff, the records were not provided, and no documentation of the request was found in the resident's progress notes. Interviews with facility staff revealed a lack of communication and follow-through regarding the request for records. The Medical Records staff member, who had been in the position for only three months, indicated that requests go through a legal process and require a fee, but there was no evidence that the records were sent or that the family was informed of any fees. The facility's policy states that records should be accessible within 24 hours of a request, yet the family had been waiting for months without resolution. The facility ultimately provided the records, but there was no documentation showing that the request had been fulfilled or communicated to the family.
Inadequate Discharge Planning and Medication Provision
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a safe and orderly discharge for a resident diagnosed with multiple medical conditions, including cerebral infarction, type 2 diabetes, and epilepsy. The resident, who required a wheelchair and had an impairment in the lower extremity, was discharged without proper coordination and communication. The care plan indicated a desire for long-term care, but the discharge was not documented or planned accordingly. The resident's family was not informed about the discharge timing, leading to confusion and a lack of medication provision at the time of discharge. The resident's family reported that they did not receive any medication or prescriptions upon discharge, which was confirmed by the facility's progress notes that lacked documentation of medication being sent with the resident. The facility's discharge policy requires that discharge instructions and medication lists be reviewed and signed by the resident or representative, but this process was not followed. The family expressed distress over the situation, highlighting the facility's neglect in ensuring the resident had necessary medications post-discharge.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting assistance to a resident, R3, which compromised his dignity and self-determination. R3, who is cognitively intact and frequently incontinent, was not assisted with toileting despite being independent with toileting prior to his transfer to the facility. His care plan did not address his toileting needs, and his wheelchair could not fit through the bathroom door. The staff did not assist him with using a bedside commode, urinal, or bedpan, and instead, he was given an adult brief and told to use it. This lack of assistance led to R3 feeling helpless, ashamed, and embarrassed as he had to lay in his own body fluids. Interviews with R3 and his sister, who is his power of attorney, revealed that R3 was dissatisfied with the care he received, as he was not provided with the necessary support to use the toilet. R3 expressed that he felt demeaned and disgusted with himself due to the situation. Staff members, including CNAs, confirmed that R3 was not taken to the bathroom and that the full body mechanical lift used for his transfers could not fit in the bathroom. The facility's policies on resident rights and activities of daily living emphasize the importance of maintaining residents' dignity and providing necessary adaptive equipment, but these were not implemented in R3's case.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for two residents, R3 and R4, who were cognitively intact and part of a sample of eight residents reviewed. R3's care plan indicated the use of Zoloft for managing depression, and the medication was administered from August 31, 2024, to September 13, 2024, without documented consent. R3 stated that he was not informed about the medication or its risks and benefits, and he did not provide verbal or written consent. The Director of Nursing, V2, provided a blank consent form and claimed that consents were in the electronic health record, but upon review, it was found that multiple residents lacked consent documentation. Similarly, R4's care plan did not address psychotropic medication use, and the resident was prescribed Trazodone and Duloxetine for major depressive disorder without documented consent. R4, who was new to the facility, stated that he did not take antidepressants or antipsychotic medications and had not given consent for such medications. R4 mentioned that he was not informed about the new medications or their potential adverse reactions, assuming his hospital medications followed him to the facility. The facility's psychotropic medication program requires informed consent and documentation of the indication for medication use, which was not adhered to in these cases.
Inadequate Tracheostomy Care for Resident
Penalty
Summary
The facility failed to provide adequate tracheostomy care for a resident, identified as R3, who was at risk for complications related to tracheostomy placement. R3's care plan required regular assessment for signs of infection and tracheostomy care, including changing the trach collar twice weekly and cleansing the trach every shift using sterile technique. However, documentation revealed that trach care was not consistently performed, with several instances where the procedure was not completed as ordered. This lack of care led to R3 experiencing shortness of breath and low oxygen saturation levels, necessitating increased oxygen support and medical intervention. R3, who was cognitively intact, reported that trach care was not provided regularly, leading to concerns about his health and safety. He expressed fear that the staff were not adequately trained or willing to perform the necessary care, resulting in his trach remaining capped when it should have been placed on a mask at night. R3 also reported experiencing drainage with an odor from his trach site, which was not addressed promptly by the facility staff. Interviews with facility staff, including LPNs, revealed inconsistencies in the provision of trach care. One LPN stated that she performed trach care when on duty, while another admitted to not performing the care, leaving R3 to manage it himself. The facility's equipment change schedule outlined specific procedures for trach care, which were not followed, contributing to R3's deteriorating condition and eventual transfer to a local hospital for further evaluation and treatment.
Failure to Arrange Transportation for Dialysis Appointment
Penalty
Summary
The facility failed to arrange necessary transportation for a resident, R16, who required dialysis treatment for a clogged dialysis shunt. This failure resulted in R16 missing a critical appointment at a vascular clinic, which was necessary to address the shunt issue. The missed appointment led to ineffective dialysis procedures, as the resident's dialysis access points were compromised, and the facility did not have an alternative plan to ensure the resident received the required medical attention. R16's medical history includes end-stage renal disease (ESRD), anemia, chronic obstructive pulmonary disease, and hypertension, among other conditions. The resident is cognitively intact and relies on dialysis to remove waste products and excess fluid from the blood. The report details that R16's dialysis shunt was clogged, and despite attempts to unclog it, the issue persisted. The facility's failure to provide transportation to the vascular clinic appointment meant that the resident's dialysis access remained compromised, posing a serious risk to their health. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that the transportation issue was due to a lack of communication and coordination within the facility. The dialysis staff did not appropriately communicate the appointment details to the transportation coordinator, resulting in the missed appointment. Consequently, the resident was sent to the emergency room, where no intervention was performed, as the hospital preferred such procedures to be handled by specialists. This series of events highlights the facility's neglect in ensuring the resident's access to necessary medical care.
Inadequate Food Portioning and Inconsistent Meal Service
Penalty
Summary
The facility failed to ensure that food was served in appropriate portions for several residents, leading to dissatisfaction and potential nutritional inadequacies. Observations and interviews revealed that residents received smaller portions than documented on the facility's menu. For instance, one resident reported receiving only four chicken nuggets and a few fries, contrary to the menu's specification of seven nuggets and a half-cup of fries. Another resident, at moderate risk for weight loss, also reported receiving insufficient portions and noted that sometimes the facility ran out of food. The cook confirmed that the main meal sometimes ran out and was substituted with an alternate, but there was no consistent portion control. Additionally, during a meal service observation, it was noted that the dietary staff did not weigh the meat portions, resulting in inconsistent serving sizes. Residents received varying amounts of pork and bread dressing, with no standardization in portion sizes. The cook admitted to not having a way to measure the portion size accurately and was unsure of the exact portion size to serve. The facility administrator acknowledged the absence of a policy related to serving appropriate portion sizes, contributing to the inconsistency in meal servings.
Failure to Document Code Status for Residents
Penalty
Summary
The facility failed to obtain and properly document code status for five residents (R58, R261, R264, R265, R266) out of a sample of 43 reviewed for advanced directives. The deficiency was identified through interviews and record reviews. For instance, R261's electronic health record did not list a code status upon review, and the POLST form was only completed after the surveyor's request. Similar issues were found with R58, R264, R265, and R266, where their code statuses were not documented in their electronic health records until after the surveyor's inquiry. R261 was admitted with diagnoses including type 1 diabetes mellitus and end-stage renal disease, but their code status was not listed until a later date. R58, admitted with traumatic subdural hemorrhage and paranoid schizophrenia, also had no code status listed initially. R266, with diagnoses including encephalopathy and systolic heart failure, similarly lacked a documented code status. R264, admitted with a femur fracture and acute kidney failure, had a discrepancy between the POLST form and the electronic health record. R265, with acute myocardial infarction and substance abuse issues, also had no initial code status documentation. The Director of Nursing (DON) and the Administrator acknowledged the issue, stating that code status should be addressed as soon as possible after admission. The facility's policy on advance directives and DNR orders mandates that a discussion of advance directives should take place upon admission, and the POLST form should be scanned into the medical record. However, this policy was not followed for the five residents in question, leading to the deficiency noted in the report.
Failure to Ensure Palatable and Appetizing Meals
Penalty
Summary
The facility failed to ensure palatable and appetizing meals for five residents who were reviewed for food palatability and temperature. Resident 18, who was cognitively intact and on a regular diet, reported that the food was not good and often cold. Resident 13, also cognitively intact and on a regular diet, described the food as horrible and resorted to ordering meals from outside the facility. Resident 24, on a regular diet with double portions, referred to the facility food as 'crap on a plate.' Resident 33, on a regular diet with double portions and fortified pudding, stated that the food could be better. Resident 267, with diagnoses including protein calorie malnutrition and end-stage renal disease, had previously filed a grievance about cold breakfast food, which was confirmed. Additionally, a grievance from a Resident Council Meeting documented that vegetables were overcooked at times, which was also confirmed. On May 9, 2024, test tray temperatures were obtained on the 300 Hall after the last resident hall tray was served. The scrambled eggs measured 112°F, the orange juice measured 60°F, and the cranberry juice measured 61°F. These temperatures were below the facility's policy requirements, which state that hot foods should be served at 135°F or higher and cold foods should be served at or below 41°F. The facility's administrator stated that she expects staff to follow food service policies, but the observed temperatures indicated non-compliance with these policies.
Failure to Provide Adequate Alternative Food Choices
Penalty
Summary
The Facility failed to follow their alternative menu for six residents reviewed for alternative food choices. Residents reported dissatisfaction with the limited food alternatives provided, specifically noting that grilled cheese was often the only option available. For instance, one resident on a No Added Salt (NAS) diet expressed that there was too much pork served and no good substitutes offered. Another resident on a No Concentrated Sweets/No Added Salt (NCS/NAS) diet stated that the Facility never cooked enough food, and the substitute was always grilled cheese. Similar complaints were echoed by other residents, who mentioned that if they did not like the meal, they were only offered grilled cheese or leftovers, which they found unappealing. During a Group Resident Council Meeting, multiple residents confirmed that grilled cheese was the only alternative if they did not want the meal served. The Regional Ombudsman also corroborated these complaints, stating that for the past seven years, the only alternatives had been grilled cheese or leftovers, despite numerous discussions with the Facility about this issue. The Facility's Dining and Food Preferences Policy, revised in September 2017, mandates that individual dining, food, and beverage preferences be identified for all residents. The policy also requires that any resident who refuses food or beverage be offered an alternative selection of comparable nutritional value. However, the Facility's undated Always Available Menu listed limited options such as deli sandwiches, jelly sandwiches, grilled cheese, mixed fruit cups, cottage cheese, side salads, and mashed potatoes. Despite these listed alternatives, staff interviews revealed that grilled cheese was predominantly offered as the alternative meal. The Dietary Manager and a Certified Nursing Assistant confirmed the limited options, with the CNA mentioning that hamburgers had only recently been added as an alternative. The Administrator stated that she expects staff to follow food service policies, but the evidence indicates that the Facility did not adhere to its own policies regarding alternative food choices.
Infection Control Deficiencies During Dialysis Treatment
Penalty
Summary
The facility failed to maintain proper infection control practices during dialysis treatment for seven residents. Observations revealed that staff members, including a registered nurse and a patient care technician, were not wearing appropriate personal protective equipment (PPE) such as gloves, gowns, or masks while performing dialysis procedures. Additionally, syringes containing heparin flush solution were improperly stored on the counter behind the nurse's desk, labeled with the names of the residents. The staff also failed to use sterile gauze and tape to cover dialysis sites after needle removal, and there was a lack of proper hand hygiene practices observed among the staff members. For instance, a patient care technician was seen changing gloves without using hand sanitizer or washing hands in between tasks, and another staff member attempted to transfer a resident into a dialysis chair that had not been cleaned or sanitized after use by another resident. The cleaning process itself was inadequate, as a paper towel soaked in a bleach and water solution of unknown concentration was used to clean multiple surfaces. The Director of Nursing acknowledged that all staff, including dialysis staff, are expected to follow proper infection control practices. The facility's policy dated April 2024 was intended to provide guidance on caring for dialysis residents, but the observed practices did not align with this policy.
Failure to Schedule Specialist Appointment
Penalty
Summary
The facility failed to transcribe and carry out a physician's order for a specialist appointment for a resident diagnosed with unspecified cirrhosis of the liver, malignant neoplasm of the colon, ascites, thrombocytopenia, and decreased white blood cell count. The physician's order, dated 4/19/24, instructed a referral to a hematologist for leukopenia and thrombocytopenia. However, the appointment was not scheduled, as confirmed by the transportation/appointment coordinator and the Assistant Director of Nursing (ADON). The resident's lab results indicated critically low white blood cell and platelet counts, which were not addressed in a timely manner due to the missed appointment. The facility's policy on appointments and transportation, dated 8/2018, requires staff to verify and schedule appointments, but it does not cover the making of initial appointments. The failure to schedule the hematologist appointment was acknowledged by the transportation/appointment coordinator and the ADON. The physician noted that the delay in the appointment would not significantly impact the resident's chronic condition, but the facility's failure to follow through on the physician's order represents a lapse in the standard of care expected for the resident's medical needs.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for two residents, R3 and R4, as required by regulations. R3's daughter, V10, requested medical records on 2/9/2024 and provided all necessary documentation by 2/15/2024. Despite multiple follow-ups, V10 did not receive the records, and the facility's Medical Records worker, V5, stated that the request was sent to the corporate office, but no updates were provided. Similarly, R4's guardian, V9, requested medical records in early March and faced delays and lack of communication from the facility. V9 was informed about the need to pay for the records and received an invoice on 4/12/2024, but still did not receive the records by the time of the survey. The facility's policy did not specify a time frame for processing such requests, contributing to the delay and confusion. Interviews with staff revealed a lack of clarity and responsibility in handling medical record requests. V5, the Medical Records worker, and V11, the Corporate Consultant, indicated that the requests were forwarded to a data processing company, but they had no further information or updates. V12, an employee of the data processing company, confirmed receiving the request for R4's records and sending an invoice but had no record of R3's request. The facility's Administrator, V1, acknowledged awareness of the requests but was unaware of the status or any follow-up actions. This lack of coordination and communication resulted in the failure to provide timely access to medical records for the residents involved.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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